Medical issues about Methadone : What the counselor needs to know

1. Medical issues about Methadone :What the counselor needs to know Judith Martin, MD Medical Director The 14th Street Clinic, Oakland, CA www.14thstreetclinic.org

2. Counseling Staff

3. THE DOSING WINDOW

4. 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)

5. 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!

6. Number of new non-medical users of therapeutics (NSDUH, 2002)

7. Commonly Abused Opioids Diacetylmorphine (Heroin) Hydromorphone (Dilaudid) Oxycodone (OxyContin, Percodan, Percocet, Tylox) Meperidine (Demerol) Hydrocodone (Lortab, Vicodin)

8. Commonly Abused Opioids (continued) Morphine (MS Contin, Oramorph) Fentanyl (Sublimaze) Propoxyphene (Darvon) Methadone (Dolophine) Codeine Opium

10. 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?

11. Talking to patients about addiction treatment models Medical Recovery Spiritual Psychodynamic Behavioral

12. ADDICTION AS A CHRONIC ILLNESS Chronic relapsing condition which untreated may lead to severe complications and death.

13. 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.

14. 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?

15. How is methadone better than heroin? • Legal • Avoids needles • Known amount ingested

16. 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.

17. IDU, pattern of heroin injection over 3 days From Dole, Nyswander and Kreek, 1966

18. Methadone Simulated 24 Hr. Dose/ResponseAt steady-state in tolerant patient “Loaded” “High” “Abnormal Normality” Normal Range“Comfort Zone” Dose Response Subjective w/d “Sick” Objective w/d Time 0 hrs. 24 hrs. Opioid Agonist Treatment of Addiction - Payte - 1998

19. 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

20. 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?

21. Methadone Simulated 24 Hr. Dose/ResponseAt steady-state in tolerant patient “Loaded” “High” “Abnormal Normality” Normal Range“Comfort Zone” Dose Response Subjective w/d trough “Sick” Objective w/d Time 0 hrs. 24 hrs. Opioid Agonist Treatment of Addiction - Payte - 1998

22. What is the right dose? • Eliminate physical withdrawal • Eliminate ‘craving’ • Comfort/function: usually trough is 400-600 ng/ml, peak no more than twice the trough. • Not oversedated • Blocking dose

23. “How Much???? Enough!!!” Tom Payte, MD

24. Ref: J. C. Ball, November 18, 1988 Slide adapted from Tom Payte

25. 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?

26. Relapse to IV drug use after MMT105 male patients who left treatment Percent IV Users Treatment Months Since Stopping Treatment Adapted from Ball & Ross - The Effectiveness of Methadone Maintenance Treatment, 1991 Opioid Agonist Treatment of Addiction - Payte - 1998

27. “How Long??? Long Enough!!” Tom Payte, MD

28. 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?

29. 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

30. 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

31. Crime among 491 patients before and during MMT at 6 programs Crime Days Per Year Adapted from Ball & Ross - The Effectiveness of Methadone Maintenance Treatment, 1991 Opioid Agonist Treatment of Addiction - Payte - 1998

32. HIV CONVERSION IN TREATMENT HIV infection rates by baseline treatment status. In treatment (IT) n=138, not in treatment (OT) n=88Source: Metzger, D. et. al. J of AIDS 6:1993. p.1052 Opioid Maintenance Pharmacotherapy - A Course for Clinicians - 1997

33. 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

34. Credit: Don Wesson, MD

36. Buprenorphine, Methadone, LAAM: Treatment Retention 100 73% Hi Meth 80 60 58% Bup Percent Retained 53% LAAM 40 20 20% Lo Meth 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 Study Week Johnson et al, 2000

37. Buprenorphine, Methadone, LAAM:Opioid Urine Results 100 All Subjects 80 LAAM 49% 60 Bup 40% Hi Meth Mean % Negative 40 39% Lo Meth 20 19% 0 1 3 5 7 9 11 13 15 17 Study Week

38. Effect of counseling in buprenorphine treatment (Fiellin, 2002)

39. Retention in treatment Kakko et al, 2003, 20 15 Remaining in treatment (nr) 10 Control, 6-day detox 5 Buprenorphine maintenance 0 0 50 100 150 200 250 300 350 Treatment duration (days)

40. 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)

41. 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.