methadone in opioid addiction david kan, m.d. university of california san francisco va medical...
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Methadone inOpioid Addiction
Methadone inOpioid Addiction
David Kan, M.D.
University of CaliforniaSan Francisco
VA Medical CenterSan Francisco
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Opium in San Francisco
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OPIATES
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Estimated Total Number of Heroin/Morphine-RelatedHospital Emergency Department Visits by Year (DAWN, 2002)
1988 1989 1990 1991 1992 1993 1994 1995 1996 199730,000
40,000
50,000
60,000
70,000
80,000
1999 2000 2001
90,000
95,000
1998
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Heroin 101 New production in South America High purity/potency (smokeable) Detoxification is of limited long-term
efficacy Most effective treatment for chronic
users is Methadone Maintenance Medications
Methadone Opioid Agonist Therapy Buprenorphine Partial Agonist Therapy Naltrexone Opioid Blockade
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Heroin Short acting opiate Immediate effects:
Heroin crosses the blood-brain barrier Heroin is converted to morphine and binds
rapidly to opioid receptors Causes euphoria Pain relief Flushing of the skin Dry mouth Heavy feeling in the extremities
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Heroin
After initial effects: Drowsy for several hours. Clouded mental function Slowed cardiac function Slowed breathing
Death by respiratory failure (overdose)
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40 Year Natural Historyof Heroin Addiction
The natural history of narcotics addiction among a male sample (N = 581). From: Yih-Ing, et. al., 2001. A 33-Year Follow-up of Narcotics Addicts. Archives of General Psychiatry, 58:503-508)
48%
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Opiate Addiction: Medications
Detoxification Opioid Substitution
Methadone (Agonist) [Illegal on outpatient basis]
Buprenorphine (Partial Agonist) [Requires special DEA license]
Non-Opioid Symptom Relief Clonidine / Lofexadine / Anti-spasmodic, anti-
diarrheals / NSAIDS for bone pain and myalgia Sleep meds
95%+ poor outcome
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Naltrexone:Efficacy vs. Effectiveness
High Efficacy: An almost perfect, long-acting blocker of
opiates Limited Effectiveness:
Most effective in monitored treatment of medical or other professionals, executives, and individuals on probation
Poor compliance in heroin-using population
Poor treatment retention
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Methadone Maintenance
The Gold Standard
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Opiate Addiction: Maintenance
Methadone Dole & Nyswander’s opioid deficiency theory
(1964). Daily Dosing, Blocking dose usually > 60 mg qd
Buprenorphine (formulated with or without naloxone) Partial Agonist (high opiate receptor avidity but
low innate activity) Daily dosing, 2-32 mg qd
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Impact of MMT on IV Drug Use for 388 Male MMT Patients in 6 Programs
PE
RC
EN
T I
V U
SE
RS
0
100
LA
ST
AD
DIC
TIO
N P
ER
IOD
AD
MIS
SIO
N
100%
81.4%
Pre- | 1st Year | 2nd Year | 3rd Year | 4th
*
*
63.3%
41.7%
28.9%
Adapted from Ball & Ross - The Effectiveness of Methadone Maintenance Treatment, 1991
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Recent Heroin Use by Current Methadone Dose
0
20
40
60
80
100
120
0 10 20 30 40 50 60 70 80 90 100
Current Methadone Dose mg/day
% H
ero
in U
se
J. C. Ball, November 18, 1988Opioid Agonist Treatment of Addiction - Payte - 1998
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Relapse to IV drug use after MMT105 male patients who left treatment
28.9
45.5
57.6
72.2
82.1
0
20
40
60
80
100
IN 1 to 3 4 to 6 7 to 9 10 to 12
Pe
rce
nt
IV U
se
rs
Months Since Stopping Treatment
Opioid Agonist Treatment of Addiction - Payte - 1998
Adapted from Ball & Ross - The Effectiveness of Methadone Maintenance Treatment, 1991
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Crime among 491 patients before and during MMT at 6 programs
0
50
100
150
200
250
300
A B C D E F
Before TX
During TX
Adapted from Ball & Ross - The Effectiveness of Methadone Maintenance Treatment, 1991
Cri
me
Day
s P
er Y
ear
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Death Rates in Treated and Untreated Addicts
0
1
2
3
4
5
6
7
8
MMT VOL DC TX INVOL DC TX UNTREATED
OBSERVEDEXPECTED
% Annual Death Rates
Slide data courtesy of Frank Vocci, MD, NIDA – Reference: Grondblah, L. et al. Acta Pschiatr Scand, P. 223-227, 1990
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Summary of Methadone Maintenance Outcomes
Gold-Standard for Opioid Treatment One of the most over-proven treatments in entire
psychiatry and drug abuse literature
Detoxification methods succeed only < 3% of the time.
Outcomes Measures Reduction of …
Death rates (8-10X reduction) Drug use Criminal activity HIV spread
Increase in … Employment Social stability Retention, medication compliance, and monitoring