5/31/98

Bibliography with abstracts for opioids Cats, Kicks and Color.

(1997). Effective Medical Treatment of Heroin Addiction. NIH Consensus Development Statement Online, NIH.

Anglin, M. D., I. J. Almog, et al. (1989). "Alcohol use by heroin addicts: evidence for an inverse relationship. A study of methadone maintenance and drug-free treatment samples." Am J Drug Alcohol Abuse 15(2): 191-207.

This study examines the relationship between the patterns of use of alcohol and heroin by narcotics addicts, and evaluates the hypothesis-- frequently reported during methadone maintenance--that this form of treatment can be causally implicated in an increased consumption of alcohol. Data were obtained on lifetime patterns of alcohol and heroin use of 375 Anglo and Chicano male addicts sampled from two treatment sources: the nonmethadone (drug-free) California Civil Addict Program (CAP) and several Southern California Methadone Maintenance (MM) programs. Repeated-measures MANOVAs revealed that alcohol and heroin consumption were inversely related throughout the addicts' careers. This pattern was evident in the addiction, treatment, and postdischarge stages of Anglo and Chicano addict careers, in both the CAP and MM samples. Consequently, the authors reject the hypothesis that increased alcohol consumption is caused solely by addicts' participation in methadone maintenance treatment. Rather, the findings suggest that addicts' alcohol use during methadone treatment reflects a lifetime pattern of increased alcohol use following any decline in heroin intake.

Anglin, M. D., G. R. Speckart, et al. (1989). "Consequences and costs of shutting off methadone." Addict Behav 14(3): 307-26.

In the face of rising fiscal conservatism, many states and localities with sizable addict populations have reduced or eliminated public funding for methadone maintenance (MM) programs and permitted private- fee-for-service programs to replace them. The social and economic costs of these changed funding policies with reference to the California experience were analyzed. A two-and-a-half year follow-up of a sample of San Diego MM clients (195 men, 129 women) terminated from a public subsidized program compared outcome results to clients from publicly funded MM programs in Orange, Riverside and San Bernardino counties (129 men, 131 women). In a secondary analysis, San Diego clients who transferred into private (fee-for-service) treatment programs were compared with those who did not transfer. Major adverse consequences were found for clients unable or unwilling to transfer to private programs: higher crime and dealing rates, more contact with the criminal justice system, and higher rates of illicit drug use were demonstrated by nontransfer clients. Moreover, the savings resulting from a reduction of MM program costs were nearly offset by increased direct costs for incarceration, legal supervision, and other government- funded drug treatment. Indirect costs were not assessed.

Ball, J. and A. Ross (1991). The effectiveness of methadone maintenance treatment. New York, NY, Springer-Verlag.

Bell, J., P. Bowron, et al. (1990). "Serum levels of methadone in maintenance clients who persist in illicit drug use." Br J Addict 85(12): 1599-602.

This study examined pharmacological factors contributing to persisting drug abuse by methadone maintenance clients. Three groups of clients, drawn from one treatment programme, were studied: persistent heroin users, persistent benzodiazepine users, and control subjects who were not using illicit drugs in addition to methadone. Persistent abusers mostly had high trough serum methadone levels, and their ongoing drug use appears to reflect a preference for a different drug effect rather than inadequate methadone dose. Several clients did have the expectation that methadone should prevent them from using other drugs; such expectations may diminish the effectiveness of treatment.

Bickel, W. K. and P. Rizzuto (1991). "The naturalistic oscillating patterns of alcohol consumption in alcoholic methadone patients." J Stud Alcohol 52(5): 454-7.

The present study examined the temporal patterns of ethanol self- administration in alcoholics. Blood alcohol concentrations (BACs) for 12 methadone maintenance patients were assessed five times per week for 2 to 8 weeks and for two additional subjects for approximately 1 year. BACs indicated periods of high consumption alternating with brief periods of abstinence. This oscillating temporal pattern was stable over time. This result is consistent with self-administration found in laboratory studies of human and non-human alcohol self-administration.

Brooner, R. K., V. L. King, et al. (1997). "Psychiatric and substance use comorbidity among treatment-seeking opioid abusers." Arch Gen Psychiatry 54(1): 71-80.

BACKGROUND: Major studies of psychiatric comorbidity in opioid abusers reported rates of comorbidity that far exceeded general population estimates. These studies were published more than a decade ago and reported on few women and few substance use diagnoses. METHODS: Psychiatric and substance use comorbidity was assessed in 716 opioid abusers seeking methadone maintenance. Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition diagnostic assessment was conducted 1 month after admission. Rates of psychiatric and substance use disorder were compared by gender, and associations were assessed between psychiatric comorbidity and dimensional indexes of substance use severity, psychosocial impairment, and personality traits. RESULTS: Psychiatric comorbidity was documented in 47% of the sample (47% women and 48% men). Antisocial personality disorder (25.1%) and major depression (15.8%) were the most common diagnoses. Patients had at least 2 substance use diagnoses, most often opioid and cocaine dependence. Demographics, substance use history, and personality variables discriminated between patients with vs without comorbidity. Psychiatric comorbidity also was associated with a more severe substance use disorder. CONCLUSIONS: Psychiatric comorbidity, especially personality and mood disorder, was common in men and women. The positive associations between psychiatric comorbidity and severity of substance use and other psychosocial problems were most consistent among those with antisocial personality.

Caplehorn, J. R., M. S. Dalton, et al. (1996). "Methadone maintenance and addicts' risk of fatal heroin overdose." Subst Use Misuse 31(2): 177-96.

An admission cohort of 296 Australian methadone maintenance patients was followed over 15 years. The relative risks of death in and out of maintenance were calculated for two age groups, 20-29 and 30-39 years. Heroin addicts in both age groups were one-quarter as likely to die while receiving methadone maintenance as addicts not in treatment. This is because they were significantly less likely to die by heroin overdose or suicide while in maintenance. Methadone maintenance had no measurable effect on the risk of death through nonheroin overdose, violence or trauma, or natural causes. A meta-analysis showed the reduction in overall mortality was consistent with the results of cohort studies conducted in the United States, Sweden, and Germany. The combined results of the five studies again indicated that methadone maintenance reduced addicts' risk of death to a quarter, RR 0.25 (95% CI 0.19 to 0.33).

Chein, I., D. Gerard, et al. (1964). The Road to H: Narcotics, Delinquency and Social Policy. New York, Basic Books, Inc.

D'Aunno, T. and T. E. Vaughn (1992). "Variations in methadone treatment practices. Results from a national study [comment] [see comments]." JAMA 267(2): 253-8.

OBJECTIVE--To examine the extent to which outpatient methadone maintenance treatment units are engaging in treatment practices that previous research indicates are ineffective (eg, inadequate dose levels); to examine factors that may be related to variation in methadone treatment practices. DESIGN--Survey of unit directors and clinical supervisors. SETTING--The study includes units that vary in terms of ownership (public, private for-profit, or private not-for- profit) and setting (eg, hospital-based, mental health center-based, or free-standing facility). PARTICIPANTS--A national random sample of 172 units participated, for an 82% response rate; the data were weighted to ensure that they were nationally representative. MAIN OUTCOME MEASURES-- Clients' awareness of and influence on doses; units' use of take-home dosages; upper limits on doses; average dose levels; unit emphasis on decreasing dosages; time when clients are encouraged to detoxify; average length of treatment. RESULTS--The data indicate that many units have treatment practices such as low average dose levels that are not effective according to the majority of previous studies. Units with higher average dose levels have longer average lengths of time in treatment. CONCLUSIONS--Steps should be taken to monitor and, if necessary, change the treatment practices of methadone units that are providing inadequate dose levels with little client input.

Dole, V. and M. Nyswander (1965). "A medical treatment for diacetylmorphine (heroin) addiction." JAMA(193): 80-84.

Dole, V. P. (1988). "Implications of methadone maintenance for theories of narcotic addiction [see comments]." JAMA 260(20): 3025-9.

Clinical success in rehabilitation of heroin addicts with maintenance treatment requires stability of the blood level in a pharmacologically effective range (optimally, 150 to 600 ng/mL)-a phenomenon that emphasizes the central importance of narcotic receptor occupation. It is postulated that the high rate of relapse of addicts after detoxification from heroin use is due to persistent derangement of the endogenous ligand-narcotic receptor system and that methadone in an adequate daily dose compensates for this defect. Some patients with long histories of heroin use and subsequent rehabilitation on a maintenance program do well when the treatment is terminated. The majority, unfortunately, experience a return of symptoms after maintenance is stopped. The treatment, therefore, is corrective but not curative for severely addicted persons. A major challenge for future research is to identify the specific defect in receptor function and to repair it. Meanwhile, methadone maintenance provides a safe and effective way to normalize the function of otherwise intractable narcotic addicts.

Dole, V. P., M. E. Nyswander, et al. (1966). "Narcotic blockade." Arch Intern Med 118(4): 304-9.

Dole, V. P., M. E. Nyswander, et al. (1968). "Successful treatment of 750 criminal addicts." Jama 206(12): 2708-11.

Eissenberg, T., G. E. Bigelow, et al. (1997). "Dose-related efficacy of levomethadyl acetate for treatment of opioid dependence. A randomized clinical trial." JAMA 277(24): 1945-51.

OBJECTIVE: To compare the clinical efficacy of different doses of levomethadyl acetate hydrochloride (known as LAAM) in the treatment of opioid dependence. DESIGN: A randomized controlled, double-blind, parallel group, 17-week study. SETTING: Outpatient facilities at Johns Hopkins University Bayview Medical Center, Baltimore, Md. PATIENTS: Opioid-dependent volunteers (N=180) applying to a treatment-research clinic. INTERVENTION: Thrice-weekly (Monday/Wednesday/Friday) oral LAAM dose conditions of 25/25/35 mg, 50/50/70 mg, and 100/100/140 mg and nonmandatory counseling. MAIN OUTCOME MEASURES: Retention in treatment, self-reported heroin use, and opioid-positive urine specimens. RESULTS: Retention was independent of subjects' sex and dose. Self-reported heroin use decreased in a dose-related manner. At final assessment, patients in the high-dose condition reported using heroin 2.5 of 30 days as compared with 4.1 or 6.3 days for patients in the medium-dose and low-dose conditions, respectively (high dose vs low dose, P.05); urinalysis results were similarly dose related. Overall, 20 (34%) of 59 patients in the high-dose condition remained opioid-abstinent for 4 consecutive weeks, as compared with 8 (14%) of 59 in the medium-dose and 7 (11%) of 62 in the low-dose conditions (P.01). Self-report and urinalysis data are consistent with a greater than 90% reduction in illicit opioid use by the high-dose group relative to pretreatment levels. CONCLUSION: Opioid substitution treatment with LAAM substantially reduces illicit opioid use. The clinical efficacy of LAAM is positively related to dose.

Finnegan, L. P. (1985). "Effects of maternal opiate abuse on the newborn." Fed Proc 44(7): 2314-7.

Infants born to opiate-dependent women frequently have low birth weights and low 1- and 5-min Apgar scores. Significant postnatal problems, excluding neonatal withdrawal, can include jaundice, infection, aspiration pneumonia, transient tachypnea, and hyaline membrane disease. Neonatal abstinence may be severe and persist for as long as 3 months. Abstinence symptoms can include central nervous system hyperirritability, gastrointestinal dysfunction, respiratory distress, tremors, fever, high-pitched cry, increased muscle tone, uncoordinated sucking and swallowing reflexes, dehydration, and possible electrolyte imbalance. During the first week of life, increased respirations associated with hypocapnia and alkalosis may occur. The Brazelton Neonatal Behavioral Assessment Scale has been used to quantify the neurobehavioral effects on neonates of narcotics administered prenatally. A marked decline in mortality rates of infants born to opiate-dependent mothers is evident. In Philadelphia, infant morbidity has been related not only to the type of maternal narcotic dependence, but also to the amount of prenatal care. Infants whose mothers received prenatal care have been found to have higher birth weights similar to infants of control mothers. Although the newborn with intrauterine exposure to narcotic agents may appear normal at birth, the effects of the pharmacologic agent may not become apparent until later in development. To obtain a more favorable outcome for the high-risk mother and child involved in the problems of perinatal addiction, several recommendations are proposed.

Glanz, M., S. Klawansky, et al. (1997). "Methadone vs. L-alpha-acetylmethadol (LAAM) in the treatment of opiate addiction. A meta-analysis of the randomized, controlled trials." Am J Addict 6(4): 339-49.

The authors conducted a meta-analysis of the reported randomized, controlled trials comparing methadone to L-alpha-acetylmethadol (LAAM) to assess the efficacy of LAAM relative to methadone in the treatment of opiate addiction. All studies were conducted in standard outpatient opiate addiction treatment clinics. Most patients were men from lower socioeconomic strata. A statistically significant risk difference favoring methadone was detected for retention-in-treatment and discontinuation of treatment because of side effects. The risk difference for illicit drug use favored LAAM, but was not significant. A small treatment difference in favor of methadone was noted. LAAM does appear to be a relatively effective alternative in the treatment of opiate addiction, more so in certain select situations.

Gronbladh, L. and L. Gunne (1989). "Methadone-assisted rehabilitation of Swedish heroin addicts." Drug Alcohol Depend 24(1): 31-7.

During its first 20 years of existence a national Swedish methadone maintenance programme received 174 heroin addicts. Programme policy, with a massive emphasis on vocational rehabilitation, and outcome data are described. In 75% of the cases the subjects abandoned their drug abuse behaviour and took up work while 25% were expelled from the programme due to violation of rules. The stability of the programme was established by 14 yearly check-ups of the percentage working and studying, which remained about 80%. The tendency towards maturing out of addiction was low in Swedish heroin addicts (6%) as evidenced by a special study including a 6-year follow-up of 34 subjects fulfilling admission criteria. Half of this group received methadone, while the other half were randomly assigned controls. The death rate among controls was at least 73 times the expected for the age group studied (20-24 years), while 81% of those receiving methadone became free of drug abuse and vocationally rehabilitated. The control group also showed a high rate of drug abuse-related morbidity. Among 34 female heroin addicted prostitutes 71% abandoned drugs and street prostitution and took up regular work.

Gronbladh, L., L. S. Ohlund, et al. (1990). "Mortality in heroin addiction: impact of methadone treatment [see comments]." Acta Psychiatr Scand 82(3): 223-7.

The mortality within a cohort of 115 street heroin addicts was studied for 5-8 years using the Kaplan-Meier survival estimate technique. This differed markedly from the relatively low mortality of 166 comparable heroin addicts given methadone maintenance treatment (MT). The street addicts' mortality rate was 63 times that expected, compared with official statistics for a group of this age and sex distribution. When 53 patients in MT were involuntarily expelled from treatment, due to violation of programme rules, they returned to the high mortality of street addicts (55 times that expected). A group of 34 rehabilitated patients who left MT with medical consent retained the low mortality of MT patients (their mortality rate was 4 times that expected). Despite this great improvement in survival, even patients in MT showed a moderately elevated mortality (8 times that expected), mainly due to diseases acquired before entering the treatment programme. It is concluded that MT exerts a major improvement in the survival of heroin addicts.

Hanson, B., G. Beshner, et al., Eds. (1985). Life With Heroin - Voices From The Inner City. Lexington, Lexington Books.

Himmelbasch, C. (1942). "Clinical Studies on Drug Addiction. Physical dependence, withdrawal and recovery." Archives of Internal Medicine(69): 766-772.

Hubbard, R. I., M. E. Marsden, et al., Eds. (1989). Drug Abuse Treatment - A National Study of Effectiveness. Chapel Hill, The University of North Carolina Press.

Hughes, P. H. and G. A. Crawford (1972). "A contagious disease model for researching and intervening in heroin epidemics." Arch Gen Psychiatry 27(2): 149-55.

Institute of Medicine (1990). A Study of the Evolution, Effectiveness, and Financing of Public and Private Drug Treatment Systems. Treating Drug Problems. Washington, DC, National Academy Press. I.

Inturrisi, C. E., W. A. Colburn, et al. (1987). "Pharmacokinetics and pharmacodynamics of methadone in patients with chronic pain." Clin Pharmacol Ther41(4): 392-401.

Concentrations of methadone in plasma, estimates of pain relief, and pupillary size were determined after a single intravenous dose (10 to 30 mg) of methadone hydrochloride to eight patients with chronic pain, five of whom had cancer. The pharmacokinetic parameter estimates reveal rapid and extensive distribution (Varea) and a slow apparent elimination half-life (t1/2) (mean Varea = 3.59 L/kg and harmonic mean t1/2 = 23 hours). The harmonic mean blood clearance is 106 ml/min, the harmonic mean renal clearance is 3.9 ml/min, the mean hepatic extraction ratio is 0.089, and plasma protein binding is 86% to 89%. These results suggest that only the free (unbound) fraction of methadone present in blood is extracted by the liver and that methadone can be classified as a low (hepatic)-extraction drug. The data were fit to a pharmacokinetic-pharmacodynamic model to obtain estimates of the steady-state plasma methadone concentration required to produce 50% of the maximum pain relief. This value varied from 0.04 to 1.13 micrograms/ml (mean = 0.29 micrograms/ml). These results indicate substantial interindividual variation in the relationship between changes in plasma methadone concentration and analgesia in patients with chronic pain receiving opioids. A pharmacokinetic-pharmacodynamic model may be useful for the individualization of analgesic dosage and therefore the optimization of pain management in patients with chronic pain.

Joe, G. W., D. D. Simpson, et al. (1991). "Unmet service needs in methadone maintenance." Int J Addict 26(1): 1-22.

Most drug abuse treatment agencies maintain a wide array of ancillary services, either on-site or through off-site referral resources, for helping meet the diverse social, medical, and psychological needs of clients. The extent to which these needs are met may be an important factor in client retention and outcomes. Perceived unmet service needs and their relationship to client outcomes were therefore studied in relationship to a framework for studying drug abuse treatment process factors. The outcomes in the present study were time in treatment and relapse to opioid use during treatment, and these were examined in relation to perceived need for services and their delivery (whether or not these services were received). The sample consisted of 590 methadone maintenance clients in 21 clinics in the RTI/TOPS data system. The results showed that the measure of unmet needs for services was not significantly related to time to relapse or to time in treatment. However, there appeared to be an indirect effect. There were differences for clinic type and a few significant interactions with other predictor variables used to study treatment process.

Kraft, M. K., A. B. Rothbard, et al. (1997). "Are supplementary services provided during methadone maintenance really cost-effective? [see comments]." Am J Psychiatry 154(9): 1214-9.

OBJECTIVE: Previous research has suggested that support services supplementing methadone maintenance programs vary in their cost- effectiveness. This study examined the cost-effectiveness of varying levels of supplementary support services to determine whether the relative cost-effectiveness of alternative levels of support is sustained over time. METHOD: A group of 100 methadone-maintained opiate users were randomly assigned to three treatment groups receiving different levels of support services during a 24-week clinical trial. One group received methadone treatment with a minimum of counseling, the second received methadone plus more intensive counseling, and the third received methadone plus enhanced counseling, medical, and psychosocial services. The results at the end of the trial period have been published elsewhere. This article reports the results of an analysis at a 6-month follow-up. RESULTS: The follow-up analysis reaffirmed the preliminary findings that the methadone plus counseling level provided the most cost-effective implementation of the treatment program. At 12 months, the annual cost per abstinent client was $16,485, $9,804, and $11,818 for the low, intermediate, and high levels of support, respectively. Abstinence rates were highest, but modestly so, for the group receiving the high-intensity, high-cost methadone with enhanced services intervention. CONCLUSIONS: This study suggests that large amounts of support to methadone-maintained clients are not cost-effective, but it also demonstrates that moderate amounts of support are better than minimal amounts. As funding for these programs is reduced, these findings suggest a floor below which supplementary support should not fall.

Kreek, M. (1991). Using methadone effectively: achieving goals by application of laboratory, clinical, and evaluation research and by development of innovative programs. Improving Drug Abuse Treatment. R. W. Pickens, C. G. Leukefeld and C. R. Schuster. Rockville, MD. National Institute on Drug Abuse Research Monograph 106.

Ling, W., C. Charuvastra, et al. (1976). "Methadyl acetate and methadone as maintenance treatments for heroin addicts. A veterans administration cooperative study." Arch Gen Psychiatry 33(6): 709-20.

This was a double-blind comparison of methadyl acetate and two dose levels of methadone hydrochloride in the maintenance of 430 street heroin addicts from 12 Veterans Administration hospitals. The starting sample consisted of 146 patients receiving low-dose methadone, 142 patients receiving methadyl acetate. Patients were first given 30 mg of both drugs, and doses were incremented by 10 mg/week until they stabilized at methadyl acetate, 80 mg three times a week, and methadone hydrochloride, 50 mg daily or 100 mg daily. Dosage was fixed for the balance of the 40-week treatment period. Safety was evaluated by clinical and laboratory observations conducted at frequent intervals throughout the study. Relative efficacy was evaluated by illicit drug use, program retention and attendance, and global staff judgments. It is concluded that methadyl acetate is as safe a drug as methadone and that it compares favorably with highdose methoadone in terms of efficacy. Both methyadyl acetate and high-dose methadone appear to be better maintenance regimens than low-dose methadone under the conditions of this study.

Ling, W., C. J. Klett, et al. (1978). "A cooperative clinical study of methadyl acetate. I. Three-times-a-week regimen." Arch Gen Psychiatry 35(3): 345-53.

This was an open clinical trial of methadyl acetate (LAAM) compared with methadone in the maintenance of 636 heroin addicts who had previously been stabilized on a maintenance regimen of methadone. The starting sample assembled by the 13 cooperating clinics were randomly assigned to continued maintenance on methadone (= 308) or crossed over to methadyl acetate (= 328) for a period of 40 weeks. The starting dose was identical to the previously established dose of methadone, but beginning with the second visit, dosage was flexible. Safety was evaluated by clinical and laboratory observations conducted at four- week intervals throughout the study. Relative efficacy was evaluated by illicit drug use, program retention and attendance, and global staff judgments. It is concluded that methadyl acetate is as safe as methadone and, when given three times a week, is an acceptable and effective maintenance drug for many heroin addicts.

McAuliffe, W. E. and R. A. Gordon (1974). "A test of Lindesmith's theory of addiction: the frequency of euphoria among long-term addicts." AJS 79(4): 795-840.

Mirin and Meyer The Heroin Stimulus.

Musto, D. The American Disease - Origins of Narcotics Control.

Novick, D. M., H. Joseph, et al. (1994). "Outcomes of treatment of socially rehabilitated methadone maintenance patients in physicians' offices (medical maintenance): follow-up at three and a half to nine and a fourth years." J Gen Intern Med 9(3): 127-30.

OBJECTIVE: To determine whether selected socially rehabilitated former heroin addicts maintained on methadone can continue successful rehabilitation while maintained on methadone by primary care physicians rather than licensed clinics. This procedure has been termed "medical maintenance." DESIGN: Cohort study with 42-111 months of follow-up. SETTING: Offices of hospital staff physicians (internists or family practitioners). PATIENTS: The 100 patients met extensive entry criteria, including five or more years in conventional methadone maintenance treatment; stable employment or other productive activity; verifiable financial support; and no criminal involvement, use of illegal drugs, or excessive alcohol use within three or more years. MEASUREMENTS AND MAIN RESULTS: Outcome measures used were retention in treatment, discharge for one of several reasons, lost medication incidents, and substance abuse. At one, two, and three years of treatment, 98, 95, and 85 patients, respectively, remained in medical maintenance. Cumulative proportional survival in treatment was 0.735 +/- 0.048 at five years and 0.562 +/- 0.084 at nine years. After 42-111 months, 72 patients remained in good standing; 15 patients had unfavorable discharges (11 for cocaine use, three for misuse of medication, and one for administrative violations); seven voluntarily withdrew from methadone in good standing (after receiving it for 9.1- 24.4 years); four died; one transferred to a chronic care facility; and one voluntarily left the program. CONCLUSIONS: Carefully selected methadone maintenance patients in medical maintenance have a high retention rate and a low incidence of substance abuse and lost medication. Voluntary withdrawal from methadone maintenance after one or two decades is possible. The authors believe that medical maintenance should be made available to appropriate patients in other localities.

Novick, D. M., E. F. Pascarelli, et al. (1988). "Methadone maintenance patients in general medical practice. A preliminary report." Jama 259(22): 3299-302.

Medical maintenance is the treatment by primary care physicians of rehabilitated methadone maintenance patients who are stable, employed, not abusing drugs, and not in need of supportive services. In this research project, physicians with experience in drug abuse treatment provided both the pharmacologic treatment of addiction as well as therapy for other medical problems, as needed. Decisions regarding treatment were based on the individual needs of the patient and on currently accepted medical practice rather than on explicit regulations. We studied the first 40 former heroin addicts who were transferred to this program from more conventional methadone clinics. At a follow-up visit at 12 to 55 months, 33 (82.5%) of 40 patients had remained in treatment; five (12.5%) had been discharged because of cocaine abuse and two (5%) had been voluntarily discharged. Personal benefits of medical maintenance include the dignity of a standard professional atmosphere and a more flexible reporting schedule. This program has the potential for improving treatment of selected methadone maintenance patients.

Preble, E. and J. Casey (1969). "Taking Care Of Business - The Heroin Users Life on the Street." The International Journal of the Addictions(4): 1-24.

Rettig, R. and A. Yarmolinsky, Eds. (1995). Federal Regulations of Methadone Treatment. Washington, D.C., Institute of Medicine, National Academy Press.

Robins, L. N. (1974). The Vietnam Drug User Returns, Special Action Office for Drug Abuse Prevention.

Schottenfeld, R. S. and H. D. Kleber (in press). Methadone, LAAM, Buprenorphine - Agonist Maintenance Treatment for Opioid Dependence. Comprehensive Textbook of Psychiatry. Kaplan and Sadock.

Schottenfeld, R. S., J. R. Pakes, et al. (1997). "Buprenorphine vs methadone maintenance treatment for concurrent opioid dependence and cocaine abuse [see comments]." Arch Gen Psychiatry 54(8): 713-20.

BACKGROUND: Buprenorphine, a partial mu-agonist and kappa-antagonist, has been proposed as an alternative to methadone for maintenance treatment of opioid dependence, especially for patients with concurrent cocaine dependence or abuse. This study evaluated whether higher maintenance doses of buprenorphine and methadone are superior to lower doses for reducing illicit opioid use and whether buprenorphine is superior to methadone for reducing cocaine use. METHODS: A total of 116 subjects were randomly assigned to 1 of 4 maintenance treatment groups involving higher or lower daily doses of sublingual buprenorphine (12 or 4 mg) or methadone (65 or 20 mg) in a double-blind, 24-week clinical trial. Outcome measures included retention in treatment and illicit opioid and cocaine use as determined by urine toxicology testing and self-report. RESULTS: There were significant effects of maintenance treatment on rates of illicit opioid use, but no significant differences in treatment retention or the rates of cocaine use. The rates of opioid-positive toxicology tests were lowest for treatment with 65 mg of methadone (45%), followed by 12 mg of buprenorphine (58%), 20 mg of methadone (72%), and 4 mg of buprenorphine (77%), with significant contrasts found between 65 mg of methadone and both lower- dose treatments and between 12 mg of buprenorphine and both lower-dose treatments. CONCLUSIONS: The results support the superiority of higher daily buprenorphine and methadone maintenance doses vs lower doses for reducing illicit opioid use, but the results do not support the superiority of buprenorphine compared with methadone for reducing cocaine use.

Silverman, K., S. T. Higgins, et al. (1996). "Sustained cocaine abstinence in methadone maintenance patients through voucher-based reinforcement therapy." Arch Gen Psychiatry 53(5): 409-15.

BACKGROUND: Chronic cocaine abuse remains a serious and costly public health problem. This study assessed the effectiveness of a voucher- based reinforcement contingency in producing sustained cocaine abstinence. METHODS: A randomized controlled trial compared voucher- based reinforcement of cocaine abstinence to noncontingent voucher presentation. Patients were selected from 52 consecutively admitted injecting heroin abusers in a methadone maintenance treatment program. Patients with heavy cocaine use during baseline period (N = 37) participated. Except where otherwise indicated, the term cocaine abuse is used in this article in a generic sense and not according to the DSM- III-R definition. Patients exposed to abstinence reinforcement received a voucher for each cocaine-free urine sample (ie, negative for benzoylecgonine) provided three times per week throughout a 12-week period; the vouchers had monetary values that increased as the number of consecutive cocaine-free urine samples increased. Control patients received noncontingent vouchers that were matched in pattern and amount to the vouchers received by patients in the abstinence reinforcement group. RESULTS: Patients receiving vouchers for cocaine-free urine samples achieved significantly more weeks of cocaine abstinence (P = .007) and significantly longer durations of sustained cocaine abstinence (P = .001) than controls. Nine patients (47%) receiving vouchers for cocaine-free urine samples achieved between 7 and 12 weeks of sustained cocaine abstinence; only one control patient (6%) achieved more than 2 weeks of sustained abstinence. Among patients receiving vouchers for cocaine-free urine samples, those who achieved sustained abstinence ( > or = 5 weeks) had significantly lower concentrations of benzoylecgonine in baseline urine samples than those who did not achieve sustained abstinence (P or = .01). Patients receiving voucher reinforcement rated the overall treatment quality significantly higher than controls (P = .002). CONCLUSION: Voucher-based reinforcement contingencies can produce sustained cocaine abstinence in injecting polydrug abusers.

Simpson, D. D. and S. G. Sells, Eds. (1990). Opioid Addiction and Treatment: A 12-Year Follow-Up. Malabar, Florida, Robert E. Krieger Publishing Co.

Stitzer, M. L. and G. E. Bigelow (1984). "Contingent methadone take-home privileges: effects on compliance with fee payment schedules." Drug Alcohol Depend13(4): 395-9.

Vaillant, G. .

Waldorf, D. (1970). "Life Without Heroin: Some Social Adjustments During Long-term Periods of Voluntary Abstention." Social Problems(18): 228-243.

Wikler, A. and F. T. Pescor (1967). "Classical conditioning of a morphine abstinence phenomenon, reinforcement of opioid-drinking behavior and "relapse" in morphine- addicted rats." Psychopharmacologia 10(3): 255-84.

Woody, G. E., A. T. McLellan, et al. (1990). "Psychotherapy and counseling for methadone-maintained opiate addicts: results of research studies." NIDA Res Monogr104: 9-23.

Data have been presented about the potential role of psychotherapy for psychiatrically impaired methadone-maintained opiate addicts. Complete data from one study, and preliminary data from a second, indicate that professional psychotherapy can be helpful as a supplement to ongoing drug-counseling services for patients having clinically significant psychiatric symptoms. If psychotherapy is to be used, care must be taken to integrate it into the ongoing clinical services of the methadone-treatment program. Not all therapists are equally adept at engaging and working with addicts. In hiring therapists, attempts should be made to identify those who are not only technically competent but also interested and comfortable with this population. It should also be emphasized that there is considerable variability among methadone programs in such vital areas as leadership, staffing patterns, organization, dosing procedures, location, physical plant, and availability of ancillary services. These administrative differences may play a significant role in the feasibility and success of attempts to use psychotherapy in drug-treatment programs. Finally, it should be noted that there is no evidence that psychotherapy cures addiction or that it can be used successfully without integrating it into other important services, such as drug counseling, methadone treatment, and the overall program structure. There is reason to believe, however, that it can provide additional and clinically meaningful benefits to that subgroup of methadone patients who are psychiatrically impaired.

Woody, G. E., A. T. McLellan, et al. (1995). "Psychotherapy in community methadone programs: a validation study." Am J Psychiatry 152(9): 1302-8.

OBJECTIVE: The authors tested the efficacy of individual psychotherapy in the rehabilitation counseling of psychiatrically symptomatic opiate- dependent patients during methadone maintenance treatment in community programs. METHOD: Volunteers in three community programs were randomly assigned to 24 weeks of counseling plus supplemental drug counseling or to counseling plus supportive-expressive psychotherapy. Follow-ups were done 1 and 6 months after treatment ended. A total of 84 subjects were evaluated at both follow-up points. RESULTS: During the study the patients receiving supportive-expressive psychotherapy and those receiving drug counseling had similar proportions of opiate-positive urine samples, but the patients receiving supportive-expressive psychotherapy had fewer cocaine-positive urine samples and required lower doses of methadone. One month after the extra therapy ended both groups had made significant gains, but there were no significant differences between groups. By 6-month follow-up many of the gains made by the drug counseling patients had diminished, whereas most of the gains made by the patients who received supportive-expressive psychotherapy remained or were still evident; many significant differences emerged, all favoring supportive-expressive psychotherapy. CONCLUSIONS: Psychotherapy can be delivered to psychiatrically impaired patients in community methadone programs. Additional counseling is associated with early benefits comparable to those from psychotherapy, but these gains are not sustained. The gains associated with psychotherapy persist and in some cases strengthen for at least 6 months after the end of therapy.

Yancovitz, S. R., D. C. Des Jarlais, et al. (1991). "A randomized trial of an interim methadone maintenance clinic [see comments]." Am J Public Health 81(9): 1185-91.

BACKGROUND. Interim methadone maintenance has been proposed as a method of providing clinically effective services to heroin addicts waiting for treatment in standard comprehensive methadone maintenance programs. METHODS. A clinic that provided initial medical evaluation, methadone medication, and AIDS education, but did not include formal drug abuse counseling or other social support services was established in New York City. A sample of 301 volunteer subjects recruited from the waiting list for treatment in the Beth Israel methadone program were randomly assigned to immediate entry into the interim clinic or a control group. RESULTS. There were no differences in initial levels of illicit drug use across the experimental and control groups. One-month urinalysis follow-up data showed a significant reduction in heroin use in the experimental group (from 63% positive at intake to 29% positive) with no change in the control group (62% to 60% positive). No significant change was observed in cocaine urinalyses (approximately 70% positive for both groups at intake and follow-up). A higher percentage of the experimental group were in treatment at 16-month follow-up (72% vs 56%). CONCLUSIONS. Limited services interim methadone maintenance can reduce heroin use among persons awaiting entry into comprehensive treatment and increase the percentage entering treatment.

Bibliographies   Resource Listing by Subject   PGY-V Home