This article was downloaded by: [Australian National University] On: 16 March 2015, At: 18:05 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK

Journal of Psychoactive Drugs Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/ujpd20

Editors' Introduction a

Joan Ellen Zweben & J. Thomas Payte a

b

14th Street Clinic and Medical Group, Oakland , California

b

Drug Dependence Associates, Inc. , San Antonio , Texas Published online: 20 Jan 2012.

To cite this article: Joan Ellen Zweben & J. Thomas Payte (1991) Editors' Introduction, Journal of Psychoactive Drugs, 23:2, 99-101, DOI: 10.1080/02791072.1991.10472225 To link to this article: http://dx.doi.org/10.1080/02791072.1991.10472225

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Editors' Introduction

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Opioid Dependence and Methadone Maintenance Treatment Joan Ellen Zweben, Ph.D. Executive Director 14th Street Clinic and Medical Group Oakland, California J. Thomas Payte, M.D. Chari person, Committee on Methadone Treatment, American Society of Addiction Medicine; Founder and Medical Director Drug Dependence Associates, Inc. San Antonio, Texas We are delighted to offer these articles examining the basic issues in methadone maintenance treatment (MMT), describing recent developments in the field, exploring problems, and raising new possibilities. We hope to stimulate interest, dispel myths, and present the unique features ofMMT. It is our aim to clarify how MMT and other pharmacotherapies fit into the overall treatment of addictive disorders. This special issue of the Journal of Psychoactive Drugs is very timely in terms of the many forces impacting on the chemical dependency field in general and specifically on opioid dependence and MMT. The role of needle sharing in the spread of AIDS among injection drug users, and consequently through them to their nonusing heterosexual partners, has prompted a serious reconsideration of MMf. Empirical investigation has confrrmed that MMT is effective in reducing the spread of human immunodeficiency virus (HIV) infection, and has thus stimulated interest among both policymakers and the treatment community. Hopefully, this renewed attention will result in overall improvement of care. Despite the fact that MMT has been shown repeatedly to be both a safe and effective treatment for heroin addiction, the modality continues to be the target of largely ideological attacks. Recent studies continue to support its effectiveness, but they have also focused attention on many problems among programs, particularly wide differences in the quality of treatment. Often these problems can be traced to a lack of guidance and supervision by the state and federal agencies charged with the responsibility to oversee and ensure compliance to existing standards of Journal of Psychoactill~ Drwgs

care. For a variety of reasons, this function has been reduced in recent years, leaving many programs largely on their own. This lack of oversight is combined with the isolation of the programs: they often exist in a vacuum without any state or national organization to provide resources that are needed to enhance effectiveness. Many program staff have had no clinical or professional training in opioid dependence and pharmacotherapy utilizing methadone. The vast literature on the subject fails to reach many who are working in MMT programs, and much of what does filter down is too esoteric to be of clinical utility. It has been estimated that treatment is available for less than one out of every five chronic opioid-dependent persons. The fact that existing programs are not inundated with requests for treatment may reflect the fact that potential patients are too discouraged to even apply or that the available treatment is unacceptable. Most programs remain full, but this may represent the shortage of available treatment rather than reflect desirable program features. No more than half the admissions are retained as long as six months. This problem can be illustrated by comparing some programs to an old, leaky wooden bucket, with the water filling it representing the patients. The bucket remains full because the water is continually being replenished. As long as no one worries about waste, one can say, "So what seems to be the problem? We have plenty of water!" Under these conditions, programs do not scrutinize the reasons for the leaks. However, when one begins to apply the consistent research findings about the strong relationship between retention in treatment and positive outcome, one is obliged to look for remedies for this early treatment dropout and fix the holes 99

Vol. 22(4), Oct-Dec 1990

Introd uction

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Zweben & Payte

clinical guidelines for the types of patients who might be best served by each treatment modality. They describe obstacles that interfere with the optimal utilization of the treatment system and suggest solutions to these problems. They also briefly report the current status of the various pharmacotherapies - such as clonidine, 1-a-acetylmethadol (LAAM), naltrexone, and buprenorphine - as well as their clinical potential and apparent limitations for treatment. Judith Martin, Thomas Payte and Joan Zweben collaborate to provide some basic material on the nuts and bolts of the medical and psychosocial treatment process. Although the research literature on methadone is enormous, it is surprising how little is devoted primarily to offering practical information and guidelines on issues that occur in everyday practice. These authors hope that their work will be useful in staff training and in stimulating further exploration of the issues that are addressed. Two of the very early works on methadone, which are now considered classics in the literature, are reprinted in this issue, with the permission of the American Med ical Association. "Narcotic Blockade," by Vincent Dole, Marie Nyswander and Mary Jeanne Kreek, which was originally published in the Archives of Internal Medicine in 1966, provides a historical perspective in a work that has maintained its clinical relevance for 25 years. It has been a little over five years since the death of Marie Nyswander, yet her contributions and energy continue to permeate the MMT field. Another classic article that has withstood the test of time is "Medical Safety and Side Effects of Methadone in Tolerant Individuals," by Mary Jeanne Kreek. This article first appeared in the Journal of the American Medical Association in 1973. As a member of the original team, Dr. Kreek has continued to make major contributions to the body of scientific knowledge related to addictive disease and its basic mechanisms, as well as to treatment based on sound scientific data. Much of the effort to defme a disease entity in heroin addiction has centered on the neurotransmitter system in the brain, such as Vincent Dole's recent presentations on receptor system dysfunction. In this monograph, Forest Tennant and colleagues examine two different abnormalities in adrenal gland metabolism, and propose that heroin addicts may suffer a corticoid deficiency during daytime hours, and an excess of cortisol in the evening. They report on a study of heroin addicts who sought treatment and who demonstrated reduced adrenal reserve, and suggest that this may explain addicts' vulnerability to AIDS, infectious diseases, and stress-related conditions (including relapse to heroin). The focus of this article is methadone's ability to normalize adrenal metabolism as one of its greatest assets. Several articles address health issues that frequently

in the bucket. It is hoped that this collection of articles will add a wide variety of perspectives from which to do so. We are very pleased to include to some comments from the leaders of two federal agencies that are central to the development, examination, and improvement of treatment for addiction. Charles R. Schuster, Director of the National Institute on Drug Abuse, and Beny Primm, Director of the Office of Treatment Improvement, describe the role of these agencies as well as their philosophies and goals for the coming decade. The quality ofleadership of these two men has not only provided direction but has improved morale, both of which have a significant impact on the activities of practitioners in the field. Several articles in this issue pertain to the development of a disease model of heroin addiction. Although Vincent Dole and Marie Nyswander proposed a "metabolic disease" concept in the early 1960s, the precise nature of that metabolic or neurohormonal defect remains unknown. Recent advances in the knowledge of brain chemistry, receptors, neurotransmitters, genetics, opioids and the immune system, brain imaging, and molecular biology strongly support that such a lesion or defect does exist and will most likely be linked to multiple genes. Further developments in this area are anxiously awaited. Despite the lack of understanding of the precise pathophysiologic mechanism, careful attention to what patients report has always indicated that for an undefmed subgroup, heroin makes them feel whole, normal, and comfortable. It is as if a vilal substance has been missing and suddenly found. When asked to describe the difference between feeling comfortable and getting high, one patient responded that getting high was the icing on the cake, but that was not what he was primarily after. Research continues to confirm clinical impressions that for some, selfmedication plays a large role in heroin addiction. Avram Goldstein, less visible to the treatment field in recent years, made some of the earliest discoveries of the endorphin system and its functioning, and did important initial work on MMT in the 1960s. Here, he offers an update on the neurobiology and pharmacology of heroin and its implications for a variety of issues in MMT, such as dosing, duration of treatment, and the importance of making available more stabilizing, longer-acting fom1s of pharmacotherapeutic agents. Thomas Payte, and Robert Newman and Nina Peyser review the history of MMT, describing some of the ways the prevailing social and political climate has impacted this treatment modality. They recount some of the ways the strong negative bias against methadone has influenced the way treatment services are delivered, and how pragmatism and empirical data may have a negligible impact on policy, regulation, and law. Richard Rawson and Walter Ling review the range of treatment modalities for heroin addiction, offering some Journal of Psychoactive Drugs

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Vol. 23(2), Apr- Jun 1991

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appear in this population. Loretta Finnegan provides an update on the care of the pregnant opioid-dependent woman. Stephen Ferrando and Steven Batki look at issues surrounding HIV-infected patients in MMf programs in terms of their medical management, psychiatric problems, and alcohol and other drug abuse. Alan Trachtenberg, James Gaudino and Carl Hanson discuss human T-cell lymphotrophic viruses I and II (HTLV-1/II), which are highly prevalent in injection drug users, in relation to the AIDS epidemic. They propose that these viruses may function as biological markers of behavioral-risk status for mv infection, and may accelerate the course of HIV infection in persons who are coinfected with HTLV-I/11 and HIV. Jim Story and Michael Stark point to the high rate of cigarette smoking in substance abusers and comment on the lack of effort to develop smoking-cessation programs for these clients. Their study showed that contrary to common stereotype, clients are concerned enough about their smoking to actually participate in a smoking-cessation program if given the opportunity, even though all considered themselves to be "extremely addicted" to tobacco. Such programs need to be tailored to the special needs and characteristics of MMf clients. On the lighter side is Thomas Payte's elaboration on the insulin-methadone analogy. As ludicrous as this "study" may seem in the insulin-diabetes context, one must realize that substituting methadone for insulin and heroin addiction for diabetes causes, for many, the absurdity to vanish. The purpose is simply to illuminate that line of thinking, and for that reason it is included here to share with a wider audience. Despite the problems and the challenges facing the MMf field, we are encouraged by a new synergism among expanding organizations and agencies concerned. The American Society of Addiction Medicine (AS AM), the National Methadone Treatment Coalition (NMfC), the National Institute on Drug Abuse (NIDA), and the National Association of State Alcohol and Drug Abuse Directors (NASADAD) represent some of the organizations that are working together to address the problems referred to above. In 1987, ASAM demonstrated its broad vision of the field of addiction medicine by establishing a committee on methadone treatment to help set ASAM policy regarding MMf. The committee is involved in education through its programs and is working with NMfC and NASADAD

JowrflDI of Psychoactive Drugs

on the development of materials to assist MMf programs. NMfC is evolving at this time from the Northeast Regional Methadone Treatment Coalition (NERMfC), which organized an Inaugural National Methadone Conference held in Boston in March 1991; it was clearly an outstanding success. The importance of a strong national and even international organization of MMT providers is incalculable. Much of the hope for a better future in this field can be attributed to the endless energy, broad vision, remarkable communication skills, and absolute dedication of Mark W. Parrino, President of NERMTC. This working alliance is further complemented by the very positive presence of interested state agencies and offices of the federal government. There is a new sense of optimism and cooperation fostered by the leadership of such men as Herbert Kleber, Charles R. Schuster, and Beny Primm to name but a few. NIDA is making research findings available to clinicians in a way that establishes important two-way communication. Work is underway to develop performance-based standards of care for MMf programs. The development of new pharmacological treatment agents has been assigned a high priority. So despite serious problems, there is some justification for guarded optimism. However, a major factor is the absence of adequate funding to move toward realization of the various goals, including improving the quality of care (with flexibility and measures of treatment outcome) and making treatment available and/or acceptable to all those in need. In closing, we would like to thank the many people whose enthusiasm and hard work made this special issue of the Journal of Psychoactive Drugs come together in such an exciting way. David E. Smith has been consistent in his commitment to reverse the dehumanization of the methadone patient and treatment provider, and has been the catalyst for numerous important educational efforts in this direction. Susan Sky, Wilma Lozada, and many other staff members of the 14th Street Clinic have provided the opportunity to work together harmoniously over a long period of time on a shared vision of a healing climate for MMf clients. Leif Zerkin and Jeff Novey have supplied both the technical expertise and support to bring this monograph to fruition. We hope this collection will enrich current and future efforts in the MMT field.

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Opioid dependence and methadone maintenance treatment.

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