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Opiate Substitution Treatment: An Overview Ron Jackson, M.S.W. Evergreen Treatment Services Seattle, WA

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HEROIN There were 32 heroin-related deaths in the first half of 2001. These represent 37% of all drug deaths. Of the heroin-related drug deaths: 27 (84.4%) had one or more other drugs in their system at the time of death. 72% of decedents were male; 94% Caucasian; 3% African-American; 3% Hispanic.

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HEROIN

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The rate of ED heroin mentions has remained stable since 1998. Treatment admissions have increased 33% since 1998. ADAM data showed male arrestees tested positive for opiates at the rate of 9.9% in 2000 and 11.7% in the first quarter of 2001. Heroin prices seem stable.

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Trends in ED mentions 1988-2000 ( rate per 100,000 population)

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ADDICTION Addiction is a brain disease shaped by behavioral and social context. Dr. Alan Leshner, Director National Institute on Drug Abuse Its like Ive got a shotgun in my mouth, my fingers on the trigger and I like the taste of gun metal. Robert Downey, Jr. Actor

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Addiction as a Brain Disease lProlonged drug use Pervasive changes in brain function that 4Persist after drug use stops 4Can be demonstrated at many levels VMolecular VCellular VStructural VFunctional

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Drug Dependence: A Chronic Medical Illness Genetic Heritability twin studies Hypertension 25-50% Diabetes Type 1: 30-55%; Type 2: 80% Asthma 36-70% Nicotine 61% (both sexes) Alcohol 55% (males) Marijuana 52% (females) Heroin 34% (males) Voluntary Choice shaped by personality and environment Pathophysiology neurochemical adaptations Treatment Response Medications effectiveness and compliance Behavioral interventions McLellan, A.T., et.al., Drug Dependence, a Chronic Medical Illness Journal of the American Medical Association 284:1689-1695, 2000.

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581 Male Heroin Addicts Followed for 33 Years Hser et al., 2001

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Adapted from: JAMA, Dec. 9, 1998, 280 (22), 1936-1943 NIH Consensus Panel on Effective Medical Treatment of Opiate Addiction 12 member multi-disciplinary panel, Nov. 1997 heard testimony from 25 experts reviewed 941 research reports published over the period Jan. 1994 - Sept. 1997 Of the various treatments available, MMT, combined with attention to medical, psychiatric, and socioeconomic issues, as well as drug counseling, has the highest probability of being effective.

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Comparing Methadone and Heroin

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LAAM: Levo-Alpha Acetylmethadol A Long-Acting Opiate Agonist Pharmacological Action Metabolites more active than parent drug Advantages One dose lasts 48 to 72 hours Fewer trips to the clinic Better heroin blockage Disadvantage Cardiac complications

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Methadone Dose: How much is enough? Leavitt, SB, et.al., When Enough is Not Enough. Mt Sinai Journal of Medicine 2000: 67(5&6): 404-411.

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Admission Criteria Adult 16-17 y.o. needs parental/guardian permission Currently physiologically dependent on an opiate Exceptions for incarcerated persons and for those who had previously successfully completed treatment Current dependence on other drugs doesnt disqualify If in treatment more than 180 days, patient needs documentation of at least one years history of opiate dependence.

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Treatment Requirements Attendance for observed dosing 6 days a week for the first 90 days (methadone); 3 days a week indefinitely (LAAM) Take-home doses permitted after 90 days but only to those patients meeting a number of criteria At least once per month observed urinalysis Some clinics have contingencies; some dont Some agencies administer alcohol breath tests; some dont Primary counselor assigned; weekly counseling for at least the first 90 days zAdditional education, i.e., HIV/HCV, family planning

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Opiate Substitution Treatment Goals Primary Goals: Reduction in of illicit opiate use. Retention in treatment for 1-2 years or more. Secondary Goals: Reduction in cocaine, alcohol, and other drug abuse. Reduction in transmission of infectious diseases by unsterile injection equipment. Reduction in criminal activity. Increase in pro-social activity employment, education, child care, etc.

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Methadone Maintenance vs. 180 Day Detoxification 12 month study of 179 opioid dependent patients randomly assigned to: lMethadone Maintenance 3mean dose=85.3mg 3for 14 months l180 Day Methadone Detoxification 3mean dose=86.3 mg prior to taper at 120 days 3followed by psychosocial Tx for 8 months K.L. Sees et al., JAMA 2000

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Adapted from: Ball & Ross, 1991. Reduction of Heroin Use By Length of Stay in Methadone Treatment Pre- treatment Admission: < 6 months stay Average Stay: 6 to 54 months Long-term: > 54 months

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Adapted from V. Dole (1989) JAMA, 282, p. 1881 Frequency of Heroin Use & Methadone Dose Level

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Drug Use & Length of Time in Methadone Treatment

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Percentage of Patients with + U/A January December, 2001 Van service

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Adapted from: Ball & Ross, 1991. The Effects of Methadone Treatment on Crime Days 70.8% Decline in Crime Days 94% n= 617

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Changes in Illegal Activity Preliminary findings, DASA, Washington State Outcomes Project, 2002

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Changes in Illegal Activity Preliminary findings, DASA, Washington State Outcomes Project, 2002

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Comparing Retention Methadone (6 mos.) vs. Drug-free (3 mos.) Preliminary findings, DASA, Washington State Outcomes Project, 2002

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Comparing 6 month Outcomes Methadone vs. Drug-free Preliminary findings, DASA, Washington State Outcomes Project, 2002

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Determining the Value of Opiate Substitution Treatment Washington State DASA, Management Report, December, 2001 1 n=726 2 n=363

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from D. Calsyn, NIDA Grant # R18DA06104 Initial & 18 Month Self-Report Data From 78 Methadone Patients

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Comparing Retention Methadone (6 mos.) vs. Drug-free (3 mos.) Preliminary findings, DASA, Washington State Outcomes Project, 2001

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Comparing 6 month Outcomes Methadone vs. Drug-free Preliminary findings, DASA, Washington State Outcomes Project, 2001

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Methadone and Criminal Justice

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from D. A. Calsyn, NIDA Grant # RA18 DA 06104 Women in Methadone Treatment: Reduction in Prostitution % of women admitting to prostitution in previous 6 months 28% 0% 13%

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Adapted from: Marsch, L.A. Addiction 93(4), 515-532, 1998. Efficacy of Methadone Maintenance: A meta-analysis Estimation of Results with Intervention* * based on the effect sizes observed in meta-analysis (# of studies)

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Adapted from: Ball & Ross, 1991. Characteristics of Successful Methadone Treatment Programs Adequate Dosing Policies Average Dose Between 60 & 120mg. Comprehensive Services Well-trained & Stable Staff Individualized Treatment Coordinated Services Medical, Counseling & Administration

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Swedish Methadone Study Before Experimental Group (Methadone) Control Group (No Methadone) Gunne & Gronbladh, 1981

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Swedish Methadone Study After 2 Years Experimental Group (Methadone) Control Group (No Methadone) Gunne & Gronbladh, 1981 d ab c dd a Sepsis b Sepsis and Endocarditis c Leg Amputation d In Prison

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Adapted from: Ball & Ross, 1991. Return to I.V. Drug Use Following Premature Termination of Treatment %IV USERS%IV USERS Months Since Dropout

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BUPRENORPHINE Partial agonist at Mu-opiate receptor less subjective high Slowly dissociates from those receptors slow onset & offset Once-a-day dosing Sublingual administration compounded with naloxone (BUP/NX) which will precipitate abrupt withdrawal if injected

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Opiate Antagonists Naloxone (NARCAN ) 3treatment for acute opiate overdose Naltrexone (ReVia ) 3detoxification from physical dependence on opiates 3opiate blocker - aid to maintenance of abstinence from opiates Clonidine (Catapres ) - not an antagonist - suppresses withdrawal symptoms