Transcript Methadone and LAAM: What the counselor needs to know

Medical issues about
Methadone :
What the counselor
needs to know
Judith Martin, MD
Medical Director
The 14th Street Clinic,
Oakland, CA
www.14thstreetclinic.org
Counseling
Staff
THE DOSING WINDOW
Epidemiology
Opioid dependence

Office of National Drug Control Policy (1999)


810,000 persons
Only 170,000 receiving medication treatment
Cost



$20 billion per year total costs (NIDA 1992)
$9.6 billion spent on heroin (ONDCP 1988-1995)
$1.2 billion per year health care costs (NIDA
1992)
Prescription opioid
abuse epidemiology
Prescription opioid use (2001), ED
reports: 90,000+ (DAWN)
 Reports of oxycodone abuse:18,000+
 Reports hydrocodone abuse: 21,000+
 Reports methadone abuse: 10,000+
1994- 2002, oxycodone 450% increase!
Bottom line: big street value!
Number of new nonmedical users of
therapeutics
(NSDUH,
2002)
Commonly Abused Opioids
Diacetylmorphine (Heroin)
Hydromorphone (Dilaudid)
Oxycodone (OxyContin, Percodan,
Percocet, Tylox)
Meperidine (Demerol)
Hydrocodone (Lortab, Vicodin)
Commonly Abused Opioids (continued)
Morphine (MS Contin, Oramorph)
Fentanyl (Sublimaze)
Propoxyphene (Darvon)
Methadone (Dolophine)
Codeine
Opium
Route of heroin administration
Treatment Entry Data System 1992-1997
100%
75%
50%
25%
0%
1992 1993 1994 1995 1996 1997
Injection
Inhalation
Smoking
Other
Four questions patients
ask:
How is methadone better for me than
heroin?
What is the right dose of methadone for
me?
How long should I stay on methadone?
What are the side effects of
methadone?
Talking to patients
about addiction
treatment models
Medical
Recovery
Psychodynamic
Spiritual
Behavioral
ADDICTION AS A
CHRONIC ILLNESS
Chronic relapsing condition
which untreated
may lead to severe complications
and death.
ADDICTION AS
CHRONIC DISEASE:
IMPLICATIONS
It is treatable but not curable.
Adjustment to diagnosis is part of
patient’s task.
There is a wide spectrum of severity.
Retention in treatment is key.
Best treatment is integrated.
Four questions patients ask:
• How is methadone better for me than
heroin?
• What is the right dose of methadone for
me?
• How long should I stay on methadone?
• What are the side effects of methadone?
How is methadone
better than heroin?
Legal
Avoids needles
Known amount ingested
Opiate effects, physical
Predictable physical effects of
administering opiates:
Tolerance: the body becomes efficient in
processing the drug and requires ever
higher doses to produce the desired effect.
 Dependence: when the drug is
discontinued there are typical withdrawal
signs and symptoms.

IDU, pattern of heroin injection over 3 days
Dose Response
Methadone Simulated 24 Hr. Dose/Response
At steady-state in tolerant patient
“Loaded”
“High”
“Abnormal Normality”
Normal Range
“Comfort Zone”
Subjective
“Sick”
w/d
Objective w/d
0
hrs.
Time
Opioid Agonist Treatment of Addiction - Payte - 1998
24
hrs.
How is methadone better than
heroin?
•
•
•
•
•
Legal
Avoids needles
Known amount ingested
Slow onset: no “rush”
Long acting: can maintain “comfort” or
normal brain function
• Stabilized physiology, hormones, tolerance
Four questions patients ask:
• How is methadone better for me than
heroin?
• What is the right dose of methadone
for me?
• How long should I stay on methadone?
• What are the side effects of methadone?
Dose Response
Methadone Simulated 24 Hr. Dose/Response
At steady-state in tolerant patient
“Loaded”
“High”
“Abnormal Normality”
Normal Range
“Comfort Zone”
Subjective
trough
“Sick”
w/d
Objective w/d
0
hrs.
Time
Opioid Agonist Treatment of Addiction - Payte - 1998
24
hrs.
What is the right dose?
Eliminate physical withdrawal
Eliminate ‘craving’
Comfort/function: usually trough is 400600 ng/ml, peak no more than twice the
trough.
Not oversedated
Blocking dose
“How Much????
Enough!!!”
Tom Payte, MD
Recent Heroin Use by Current
Methadone Dose
% Heroin Use
100
80
60
40
20
0
0
10
20
30
40
50
60
70
Methadone Dose, in mg.
Ref: J. C. Ball, November 18, 1988
Slide adapted from Tom Payte
80
90 100
Four questions patients ask:
• How is methadone better for me than
heroin?
• What is the right dose of methadone for
me?
• How long should I stay on
methadone?
• What are the side effects of methadone?
Relapse to IV drug use after MMT
105 male patients who left treatment
Percent IV Users
100
82.1
80
72.2
60
57.6
45.5
40
28.9
20
0
IN
1 to 3
Treatment
4 to 6
7 to 9
10 to 12
Months Since Stopping
Treatment
Adapted from Ball & Ross - The Effectiveness of Methadone Maintenance
Treatment, 1991
Opioid Agonist Treatment of Addiction - Payte - 1998
“How Long???
Long Enough!!”
Tom Payte, MD
Four questions patients ask:
• How is methadone better for me than
heroin?
• What is the right dose of methadone for
me?
• How long should I stay on methadone?
• What are the side effects of
methadone?
Side effects of
methadone:
General opiate effects:



Sedation/stimulation
Maintained phys. dependence (stable)
hypogonadism (not as severe as with heroin, may
be dose dependent)
Constipation
Slight QTc prolongation on ECG (Martell etal)
Sweating
Methadone treatment tied to regulated clinic
Treatment Outcome
Data
8-10 fold reduction in death rate
reduction of drug use
reduction of criminal activity
engagement in socially productive roles
reduced spread of HIV
excellent retention
Crime among 491 patients before
and during MMT at 6 programs
Crime Days Per Year
300
250
200
Before TX
During TX
150
100
50
0
A
B
C
D
E
F
Adapted from Ball & Ross - The Effectiveness of Methadone Maintenance
Treatment, 1991
Opioid Agonist Treatment of Addiction - Payte - 1998
HIV CONVERSION IN TREATMENT
35%
30%
25%
20%
IT
OT
15%
10%
5%
0%
Base line
6 Month
12 Month
18 Month
HIV infection rates by baseline treatment status. In treatment (IT) n=138,
not in treatment (OT) n=88
Source: Metzger, D. et. al. J of AIDS 6:1993. p.1052
Opioid Maintenance Pharmacotherapy - A Course for Clinicians - 1997
A FEW WORDS ABOUT
BUPRENORPHINE
“Ceiling effect” and safety
Displaced other opiates: withdrawal on
induction
Less agonist strength
Schedule 3(methadone is 2)
One form combined with naloxone
Office – based use available
Partial vs Full Opiate Mu Agonis
death
Opiate
Effect
Full Agonist
(e.g., methadone)
Partial Agonist
(e.g. buprenorphine)
Dose of Opiate
Credit: Don Wesson, MD
Percent Retained
Buprenorphine, Methadone,
LAAM:
Treatment Retention
100
80
73% Hi Meth
60
58% Bup
40
53% LAAM
20
20% Lo Meth
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
Johnson et al, 2000
Study Week
Buprenorphine, Methadone,
LAAM:
Opioid
Urine
Results
100
All Subjects
Mean % Negative
80
LAAM
49%
60
Bup
Hi Meth
40%
40
39%
Lo Meth
20
19%
0
1
3
5
7
9
11
Study Week
13
15
17
Effect of counseling in
buprenorphine treatment
(Fiellin, 2002)
Opioid positive urines
1
0.8
MM
MM+DC
0.6
0.4
0.2
0
Induction
week 2-4
week 5-7
week 8-10
Remaining in treatment (nr)
Retention in treatment
Kakko et al, 2003,
20
15
10
Control, 6-day detox
5
Buprenorphine maintenance
0
0
50
100
150
200
250
Treatment duration (days)
300
350
Pharmacotherapy in
context: correct
glossary
Abstinence includes pharmacotherapy
Maintenance, not substituion or
replacement (new term also: MAT)
Tapering from maintenance, not
detoxification, (also ‘medically supervised
withdrawal’, or MSW)
Discontinuation, not discharge
Toxicology screens: pos/neg, not
clean/dirty)
Opioid
pharmacotherapy,
summary:
Methadone, buprenorphine and LAAM all
approved by the FDA for treatment of opiate
dependence. (LAAM not currently available
from any drug company)
Best evidence so far supports maintenance.
Detoxification attempts should have
maintenance as a back up in case of relapse.