ix-Nay the ethadone-May. Wait…what decade is this?

February 1, 2008

Another one for the triumph of idiotic, unsupported public policy “positions” over the science and on-the-ground clinical experience. Apparently we’re all about the opiates, this week because today’s discussion is once again on heroin addiction. The free weekly San Diego CityBeat has the call:

Last October, the same week wildfires broke out around San Diego County, a couple thousand doctors, nurses, drug counselors and public officials gathered at the San Diego Sheraton for the annual meeting of the American Association for the Treatment of Opioid Dependence (AATOD), the national trade organization for providers of what’s known as medically assisted drug treatment. … featured speakers comprised a who’s-who of the drug-treatment world, from the current head of California’s Department of Alcohol and Drug Programs to the director of the national Center for Substance Abuse Treatment. San Diego Mayor Jerry Sanders was scheduled to give a welcome speech, though he had to cancel because of the fires.
Whitmyer, who chaired the conference’s hospitality committee, noticed an absence among attendees–no one from the County of San Diego, the region’s overseer of public-health programs, signed up to attend.
“That was a national program that was attended by 2,000 people and there was no one from the county there, in our own backyard, to learn about the benefits of medically assisted treatment,” Whitmyer said.

I mean c’mon, it is only the county housing the 2nd largest city in California and the 8th largest city in the US. What, they were distracted by the wildfires or something?

No one was there because medically assisted drug treatment, also referred to as narcotic-replacement therapy, is not a service the county provides.
Drug-treatment providers that get funding from the county operate under a drug-free model, also known as social-model treatment, meaning anyone enrolled in their programs must abstain from any substance that could result in dependence, even if that substance is helping them kick their habit. A person who enters a county drug-treatment program on methadone might as well have entered the program on heroin.

Why? Methadone for heroin addiction may not be a silver bullet but, dang, it sure helps. Well, maybe there just isn’t anybody around to learn ’em about drug abuse, eh? Those were links I could quickly find but I know there are a few research scientists at The Salk Institute for Biological Studies and the San Diego Veteran’s Administration hospital that work on drug abuse topics as well. Admittedly these folks don’t all focus on opiates and there isn’t really a big clinical research operation into heroin…but still. What’s going on?

Politics and cost–likely more the former–appear to be the reasons why

Oh joy. And the good news just keeps coming in this article:

The drug-free treatment model carries over to the criminal justice system, too. San Diego County’s Drug Court, a diversion program that offers nonviolent offenders the option to enter treatment rather than jail, forbids medically assisted treatment. And of the $9 million San Diego County receives annually to pay for Prop. 36–the statewide drug-treatment initiative that’s based on the drug-court model but with more lenient probation rules–none of that money funds medically assisted treatment.

Well, at least they have an alternative to “lock ’em up”.

Jail is where Elon Burns learned how to shoot heroin. He had been smoking the drug since he was 13 and was convicted for drug possession when he was 19. With no access to syringes, inmates fashion makeshift shafts to inject drugs. It was from one of these shafts that Burns contracted hepatitis C.

So who’s to blame anyway?

A number of people CityBeat spoke to for this story pointed to the county Board of Supervisors as the reason why methadone isn’t part of any county programs.
In a 2001 interview for a San Diego Magazine article on the rise in HIV infections in San Diego County, Supervisor Bill Horn, in response to questions about why the county doesn’t fund methadone or needle-exchange programs, said his cousin died from a heroin overdose after a failed attempt at methadone treatment.

Okay, point is made. But really, go read the article. It’s pretty meaty.
As I said at the outset, methadone is not perfect. It is an opiate, having properties much like heroin, morphine and the synthetic varieties. It is acutely reinforcing, causes dependence and abrupt discontinuation results in acute opiate withdrawal. It is a chronic medication and relapse rates after tapering off lengthy courses of methadone maintenance are quite high. Still, it can be an effective part of the public health toolkit.
I was alerted to this by someone who GivesACrap about local science/policy relationships. How about you DearReader? Do you know whether your local public health entities operate on science-based or political-opinion-based principles?

15 Responses to “ix-Nay the ethadone-May. Wait…what decade is this?”

  1. Dunc Says:

    Hmmm… Is methadone really preferable to just prescribing people heroin though? Ben Goldacre makes the argument that methadone is both more dangerous and less effective than heroin for treating heroin addiction. It seems to me that once again we’re allowing what should be medical decisions to be made on the basis of a strange puritanical morality that says that anything enjoyable is wrong, and that offenders must be purified through suffering (or death).

    However, methadone is also a dangerous drug in its own right: astonishingly, use of methadone has a higher mortality even than the use of illicit heroin, although to what extent is uncertain. For example, in 1992, there were 101 deaths from methadone, and 40 from heroin; similarly, from 1982 to 1991 there were 349 methadone deaths and 243 heroin deaths (OPCS): this is despite the fact that there are far more users of heroin, at every strata of use, by a factor of at least 3:2, than of methadone.


  2. DrugMonkey Says:

    Well Dunc, that’s why I like to provide the odd PubMed links so that people can start checking out at least the abstracts for themselves. And coming to their own conclusions. It is very easy for one to construct a summary that makes one point or the direct opposite by selective reading of the literature. Without diving into it too much just note the passage following the one you quoted:

    However, to quantify the mortality requires an accurate denominator (the number of users for each drug) and this, as we have already discussed, can only be achieved indirectly for a covert and underground activity such as drug abuse. Estimates vary widely according to the denominator used, and authors are never so disingenuous as to claim pinpoint accuracy for their figures,

    So you’d have to really pore through where the figures came from (OPCS is the only cite and wtf is that?), what populations are being described, etc.
    For the main point, however, the Goldacre link is making the argument for heroin instead of methadone, i.e., quibbling over which version of agonist therapy is best. Believe you me, public health agencies that don’t use methadone in this day and age are not looking to use heroin instead. They are against agonist therapy, period. As a sidebar, heroin for heroin addiction is not as dumb as some might think at first, the “patch” and the “gum” for smoking agonist therapy supply, you guessed it, good old nicotine.


  3. Dunc Says:

    Sorry, I think you may have misinterpreted my position… I’m all for agonist therapy, and I’m not necessarily arguing against the use of methadone. I think the decision as to which agonist to use (if agonist therapy is appropriate) should probably be made on a case-by-case basis. I find it completely bizarre and indeed disturbing that it’s not available as an option. The point I was trying to make is that we need to adopt a rational harm reduction approach, based solely on what shows good evidence of working. If that means methadone, or heroin prescription, or even full legalisation, then so be it.


  4. DrugMonkey Says:

    It was just that I doubt very much, without going into it in depth, that apples to apples methadone is “more dangerous” for treating heroin addiction. Ditto for “illicit” heroin use. I mean, c’mon.
    Still, since I haven’t delved into it myself, I had the above comments. You have to track down exactly what he is saying to even start determining if methadone is less safe than illicit use or even heroin as therapy.


  5. Dunc Says:

    What he’s saying is that it’s currently very difficult to say for certain, because there are lots of confounding factors. I was just throwing out the link an a brief glimpse of one particularly provocative part of his argument as an alternative perspective on the debate.


  6. DrugMonkey Says:

    “it’s currently very difficult to say for certain, because there are lots of confounding factors”
    The trouble is that this is a standard half-arsed denial-of-the-science position. Find one or two studies, gin up some bizarre apples-to-oranges comparison and say “well there’s controversy”.
    There. Are. Always. “Confounding”. Factors. In. Science.
    This does not mean that we cannot come to a reasonable consensus opinion at any given state of knowledge.


  7. Dunc Says:

    Have you even read the article I linked to? I’m trying to agree with you here – unless your point is that methadone is the One And Only True Way in the treatment of heroin addiction, in which case I think that’s an over=simplification.
    I am not opposed to the use of methadone. I just don’t think we should rule out the use of heroin. That’s all I’m trying to say. I am most certainly not trying to say “OMG methadone is teh evil!” It’s a perfectly reasonable treatment option. I just don’t think it should be the only option for agonist therapy.
    I do not understand how this turned into a disagreement. I guess I must have been very unclear. So, for the record:
    1. I think agonist therapy is a perfectly good treatment option (in fact, one of the best), with very good evidence of effectiveness.
    2. I think methadone is a perfectly valid option for agonist therapy.
    3. I think drug policy and treatment should be based on a rigorously scientific harm-reduction approach.
    4. I do not think drug policy and treatment options should be rejected based on an emotional or moralistic objections, as appears to be the case in San Diego.
    Is that sufficiently clear? I’m agreeing with you. I know that that’s an unusual experience for anyone trying to argue for a rational and scientific approach to the problems caused by drug addiction, but believe me, it’s true.


  8. hibob Says:

    some context on San Diego County: It’s filled with well educated people in the Biotech, Aerospace and other high tech industries. It’s one of the last places in the US to have fluoridated water, due entirely to local retreads of the John Birch Society pushing “impurifying our precious bodily fluids” type arguments, and home to several of the top 10 most conservative cities in the United States (Escondido, Poway). Needle exchange, methadone, and other reality and compassion based programs are regularly turned down by the city and the county so that politicians don’t have to deal with NIMBYism and the sentiment that addicts shouldn’t be spared the rod.
    We’re a little schizo here.


  9. DrugMonkey Says:

    (wipes eyes)
    I’m sorry, I thought you said “San Diego County doesn’t fluoridate its water”….


  10. Suesquatch Says:

    I find it astonishing that I have been accused of “pushing pain meds” because, as a nurse, I awakened a physician late at night to get the morphine upped for a man dying of a subdural hematoma who was moaning so loudly that I could hear him from the nurses’ station. He died on the next shift, with a nurse who “doesn’t like” narcotics, so he died in pain.
    We’re a bunch of control-freak Puritans. Why even cure heroin addicts? Let them shoot junk and remove organized crime and the Taliban from the chain of supply. Provide them with clean needles and substantially reduce new HIV and Hep B & C infections. It’s better that someone dies of an infectious disease than an o/d?
    The best was telling a doc, on an 87- year- old alcoholic who had just been detoxed, “Please don’t d/c the Valium. He’ll seize or stroke.” I was pooh-poohed, the benzos were d/ced, he stroked the next day, died within two.


  11. DrugMonkey Says:

    Dunc? Ease up my man. The number of readers here dwarfs the number who actually comment. Not everyone clicks through links. Part of what I do is see how comments might read to the rest of the audience and try to put it in context.


  12. Dunc Says:

    I was cool right up until I was accused of “standard half-arsed denial-of-the-science”.


  13. Couple of issues here:
    01.) Methadone is one of the safest, most researched drugs to be prescribed. Proper monitoring includes: Being assessed by a health treatment team consisting of a Physician, Nurse and Addictions Counselor, daily dosing of Methadone in a crystallized juice suspension at a clinic until on a stable dosage, and randomized drug screening for illicit substances and methadone metabolite. When this system is in place you do not have outrageous mortality statistics like that.
    02.) When the medical examiner writes up his final report on death often it includes overdose due to toxicity related to such and such drugs. Methadone is not usually the culprit it most likely is after a patient has taken his dose and it is wearing off… then he takes more heroin or morphine than he should because he wasn’t getting high off the Methadone. Other times it can be from death in the hospital if a patient is administered Naloxone which shakes off all the opioids (Methadone inclusive) however it has less of a half life so this client leaves the hospital and 12 hours later he takes another hit and !Bam! the methadone kicks in and OD! Another point is that Methadone is also a primary care regiment for pain management are some of those deaths attributed to this?
    03.) Methadone Maintenance should be a last resort (after medical detox). The commitment is 6 months to see positive outcomes from stability.
    Patients who seek MMT (Methadone Maintenance Treatment) are inevitably looking for help and this alone needs recognition one way or the other.
    What this person is saying by coming forward is, “I no longer wish to put myself or others in harms way, I neither wish to steal nor cheat you of your livelihood today in order to feed my addiction… please help me reach my goals one way or another!”
    Suboxone is making significant headway and hopefully this will fill part of that void.


  14. Just a note to the Heroin vs. Methadone argument:
    Heroin is short acting and intrusive when it comes to normalization of daily functioning: maintaining on it requires that your body start to crave it and feel withdrawal 4-5x more often than Methadone which when stabilized lasts 24 – 48 hrs per dose.
    Withdrawal 4x a day or once a day for the next xxyears?


  15. DuWayne Says:

    Methexpert –
    Just out of curiosity, what are your thoughts on the use of clonidine for detox? I am not terribly familiar with heroin detox, having less experience with heroin junkies than any other flavor junkie. I did get some experience last year, that I intend on discussing at my blog and would love to get some input on non-opioid treatment of heroin addiction, versus opioid treatment.


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