nysdoh/ai the role of methadone in hiv prevention and treatment sharon stancliff, md medical...
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NYSDOH/AI
The Role of Methadone in HIV Prevention And Treatment
Sharon Stancliff, MDMedical ConsultantAIDS InstituteNew York StateDepartment of Health
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Drug Use and HIV
Injection of heroin and cocaine is the driving force behind HIV in New York State
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Addiction
• Opiates interact with receptors for endogenous peptides.
• Short term changes in the dopamine secreting neurons, such as atrophy are documented
• Long term changes are suspected.
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Genetics• Twin and adoption studies show a strong
familial trend in alcoholism
• Addictive disorders are common among the families of heroin addicts
• Anthenelli
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“Drug Addiction is a Brain Disease”
Alan Leshner, PhDNational Institute of Drug AbuseDirector
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National Institute of Health
“Methadone is the most effective treatment for heroin addiction.”National Institute of Health Consensus Development Conference on the Medical Treatment of Heroin Addiction
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Methadone
• A synthetic opiate with a 24-36 hour half-life
• Methadone Maintenance Treatment (MMT) was first implemented by Dole and Nyswander in the 1960s as most “detoxed” addicts relapsed to heroin use
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Methadone
• Usual effective dose: 80-120 mg range:5mg- >500 Clinical response guide dose
• Rettig, Leavitt
• 80-90% of those stopping MMT will return to heroin use so treatment is long term
• Ball, Magura
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Methadone
• Safe during pregnancy• Kandall
• No known long term detrimental effects• Novick
• MMT is usually accompanied by counseling and sometimes other requirements
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Benefits of Methadone Maintenance
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Reduction in Heroin Use
• Given a sufficient dose virtually all heroin users will stop using heroin
• At lesser doses heroin use is decreased.
• Ball 1991
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MMT patients are 3-6 times less likely to become HIV positive when compared to out-of-treatment heroin users.Metzger, Drucker, Gibson, Hartel
HIV Prevention
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Reduction in HIV seroconversion: a prospective study
• Comparison of opiate users in and out of methadone treatment
• Those out of treatment reported more risk behavior for HIV
• In treatment: 3.5% seroconverted, Out-of-treatment 22% seroconverted
• Metzger
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HIV positive heroin users on methadone are hospitalized less often and live longer than their counterparts who are not on methadone
Weber, Newschaffer, Laine
Improved outcome in HIV
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Other Benefits• A fourfold reduction in suicide
• A fourfold reduction in lethal overdose
• Capelhorn
• Reductions in sex work• Bellis
• Reduction in crime• Hubbard, Appel
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Issues in Methadone Prescribing
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Over regulation
• Available only in methadone clinics
• Frequent attendance required
• Limited number of slots
• Medical maintenance has been shown to be successful outside of these constraints
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Under Dosing
• A 1995 study of selected MMTPs found an average dose of less than 59mg
• 2/3s of the clinics set a dose ceiling of 80-100mgs
• D”Aunno
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Premature discharge
• A 1995 study found that the majority of clinics encourage detox after only 1 year of treatment
• Relapse can be deadly- Zanis found 8.2% mortality among 110 pts. leaving MMTP but only 1.2% among 397 remaining in treatment
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Misunderstandings about methadone
• Patients often believe that methadone causes bone or liver damage.
• Physicians may have misconceptions about pain management in methadone patients.
• It is also erroneously believed that MMT leads to cocaine use.
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MMT patients are judged by:
• Family
• Friends
• Physicians
• Social service providers
• Employers
• Politicians
• Drug users
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Stigmatization by drug Treatment Providers
• MMT patients are discouraged from speaking at Narcotics Anonymous meetings
• Narcotics Anonymous Bulletin
• Many facilities treating cocaine and alcohol abuse bar methadone
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Role of the Primary Care Provider
• Education of current and potential MMT patients and their families
• Understanding medical issues such as drug interactions
• Working with clinics to ensure the best possible care for patients
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Drug InteractionsDRUGS WHICH MAY LOWER
PLASMA LEVELS OF METHADONE
• Phenobarbital
• Carbamazepin (Tegretol)
• Phenytoin (Dilantin )**
• Ritonavir (Norvir)
** Major effect, may require large methadone dose increases
• Nevirapine (Viraimmune)**
• Rifampin**
• Efavirenz (Sustiva)**
• Abacavir (Ziagen)
• ethanol (chronic use)
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Drug Interactions II• DRUGS WHICH MAY INCREASE PLASMA LEVELS OF METHADONE
(none are major problems)
• Amitriptyline (Elavil)
• Cimetidine (Tagamet)
• Diazepam (Valium)
• Ethanol ( acute use)
• Ketoconazole (Nizoral)
• Zidovudine (AZT) levels may be increased by methadone.
• DRUGS WHICH ARE CONTRAINDICATED
• Pentazocine (Talwin),
• Tramadol (Ultram)
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For more HIV-related resources, please visit www.hivguidelines.org