Symptom complaints of patients maintained on methadone, LAAM (methadyl acetate), and naltrexone at different times in their addiction careers

Dissatisfaction with opioid maintenance treatment partly explains reported side effects of medications

BACKGROUND

Drop-out is a core problem in opioid maintenance treatment (OMT), but patients' reactions to and acceptance of the various OMT medications are insufficiently investigated. In Norway, there has been vocal patient resistance to the newest medication, buprenorphine-naloxone (BNX), and complaints have focused on the side effect profile. There has been no comparison of patient satisfaction and side effects of the three most common OMT medications.

AIM

To compare patient satisfaction with OMT and side effects of BNX, buprenorphine monopreparate (BUP), and methadone (MET) as reported by patients.

METHODS

Data were drawn from a national peer-to-peer survey developed by a patient advocacy group. The survey engaged more than 1000 OMT patients, corresponding to one seventh of OMT patients in Norway. The associations between side effects, treatment satisfaction, and patient characteristics were tested in multinomial logistic regressions.

RESULTS

High patient satisfaction with OMT overall was reported despite lower satisfaction with medication itself and widely prevalent side effects. Among each medication group, dissatisfaction with medications or OMT in general along with poor health status increased the relative risk ratio of reporting the heaviest side effect burden. MET users reported the highest side effect burden and BNX users the lightest, but BNX users were more dissatisfied with their medication.

CONCLUSIONS

Side effects are a concern for nearly all OMT patients, and they do not appear to accumulate with age or length of treatment. BNX users' dissatisfaction with their medication is of particular concern, and expectations and preferences of medication may be influencing their dissatisfaction.

Correlates of perceived risk of HIV infection among persons who inject drugs in Tijuana, Baja California, Mexico

OBJECTIVE

We identified correlates of perceived risk of HIV infection among persons who inject drugs (PWID) in Tijuana.

MATERIALS AND METHODS

PWID ≥18 years of age who injected drugs in the past month were recruited between 2006-2007 and completed risk assessment interviews and serologic testing for HIV, syphilis, and tuberculosis. Logistic regression was used to determine factors associated with high-perceived risk of HIV infection.

RESULTS

Among 974 PWID, HIV prevalence was 4.4%; 45.0% of participants perceived themselves to be more likely to become HIV infected relative to other PWID in Tijuana. Participants who reported high-perceived risk of HIV infection participated in high-risk behaviors such as injecting with used syringes, transactional sex, and were less likely to have had an HIV test.

CONCLUSIONS

Recognition of HIV infection risk was associated with high risk behaviors and markers of vulnerability. Findings support efforts to encourage HIV testing and access to health care for this vulnerable population.

Clinical safety of 1500 mg oral naltrexone overdose

This case represents a clinical overdose of the largest known dose of oral naltrexone, equivalent to the taking of a whole bottle of the oral naltrexone preparation. The patient's intention was to control craving for alcohol and opiates. The patient quickly settled with expectant management. As such it demonstrates that earlier concerns that have been voiced in this area, particularly relating to naltrexone-related hepatotoxicity and depression, may have been overstated, at least in the experience of this patient. This patient's course was marked only by gastric irritation, of which she had some history. As such the present profile provides case report evidence consistent with more robust views of the patient safety of naltrexone itself, and opposing more cautious views. Her polydrug craving was suppressed for a period of 2 weeks, which raises the important question of the mechanism of action of naltrexone's generalised suppression of refractory hedonic consumptive addictive behaviours.

Effects of sleep deprivation on sleep homeostasis and restoration during methadone-maintenance: a [31]P MRS brain imaging study

Insomnia afflicts many individuals, but particularly those in chronic methadone treatment. Studies examining sleep deprivation (SD) have begun to identify sleep restoration processes involving brain bioenergetics. The technique ([31])P magnetic resonance spectroscopy (MRS) can measure brain changes in the high-energy phosphates: alpha-, beta-, and gamma-nucleoside triphosphate (NTP). In the present study, 21 methadone-maintained (MM) and 16 control participants underwent baseline (BL), SD (40 wakeful hours), recovery1 (RE1), and recovery2 (RE2) study nights. Polysomnographic sleep was recorded each night and ([31])P MRS brain scanning conducted each morning using a 4T MR scanner (dual-tuned proton/phosphorus head-coil). Interestingly, increases in total sleep time (TST) and sleep efficiency index (SEI) commonly associated with RE sleep were not apparent in MM participants. Analysis of methadone treatment duration revealed that the lack of RE sleep increases in TST and SEI was primarily exhibited by short-term MM participants (methadone <12 months), while RE sleep in long-term MM (methadone >12 months) participants was more comparable to control participants. Slow wave sleep increased during RE1, but there was no difference between MM and control participants. Spectral power analysis revealed that compared to control participants; MM participants had greater delta, theta, and alpha spectral power during BL and RE sleep. ([31])P MRS revealed that elevations in brain beta-NTP (a direct measure of ATP) following RE sleep were greater in MM compared to control participants. Results suggest that differences in sleep and brain chemistry during RE in MM participants may be reflective of a disruption in homeostatic sleep function.

Long-term methadone maintenance reduces protracted symptoms of heroin abstinence and cue-induced craving in Chinese heroin abusers

BACKGROUND

Cession of heroin use may be followed by a protracted-abstinence (PA) syndrome consisting of craving, negative mood, and physiological changes. PA symptoms have rarely been compared between drug-free and methadone-maintained former heroin users after similar lengths of heroin abstinence.

METHODS

Seventy former heroin users were included in one of four groups: in day 15-45 of methadone maintenance therapy (short-term MMT), in month 5-6 of MMT (long-term MMT), opiate-free for 15-45 days after methadone-assisted heroin detoxification (short-term post-methadone), and opiate-free for 5-6 months after methadone-assisted heroin detoxification (long-term post-methadone). PA symptoms (negative mood, dyssomnia, somatization, and craving), and blood pressure and pulse were assessed pre- and post-neutral videotape and pre- and post-heroin videotape.

RESULTS

Dyssomnia and the total PA score were worst in short-term post-methadone participants, mood was best in long-term MMT participants, and cue-induced craving was least severe in long-term MMT participants. Blood pressure and pulse did not differ across groups.

CONCLUSIONS

Even after acute withdrawal, the first months of heroin abstinence after methadone-assisted detoxification may be more difficult in terms of cue-induced craving and other PA symptoms than the first months of heroin abstinence during MMT. Our findings add to the literature supporting MMT for prevention of cue-induced heroin craving.

LAAM maintenance vs methadone maintenance for heroin dependence

BACKGROUND

LAAM and methadone are both full mu opiate agonists and have been shown to reduce dependence on heroin when given continuously under supervised dosing conditions. LAAM has a long duration of action requiring dosing every two or three days compared to methadone which requires daily dosing. LAAM is not as widely available internationally as methadone, and may be withdrawn from the market following ten cases of life-threatening cardiac arrhythmias and an association with QT prolongation.

OBJECTIVES

To compare the efficacy and acceptability of LAAM maintenance with methadone maintenance in the treatment of heroin dependence.

SEARCH STRATEGY

We searched MEDLINE (January 1966 to August 2000), PsycINFO (1887 to August 2000), EMBASE (January 1985 to August 2000), and the Cochrane Controlled Trials Register (Issue 2 2000). In addition we hand searched NIDA monographs until August 2000 and searched reference lists of articles.

SELECTION CRITERIA

All randomised controlled trials, controlled clinical trials and controlled prospective studies comparing LAAM and methadone maintenance for the treatment of heroin dependence and measuring outcomes of efficacy or acceptability were included.

DATA COLLECTION AND ANALYSIS

Data on retention in treatment, heroin use, side-effects and mortality were collected by two reviewers independently. A meta-analysis was performed using RevMan. Discrepancies were resolved by consensus.

MAIN RESULTS

Eighteen studies, (15 RCTs, 3 Controlled prospective studies) met the inclusion criteria for the review. Three were excluded from the meta-analysis due to lack of data on retention, heroin use or mortality. Cessation of allocated medication (11 studies, 1473 participants) was greater with LAAM than with methadone, (RR 1.36, 95%CI 1.07-1.73, p=0.001, NNT=7.7 (or 8)). Non-abstinence was less with LAAM (5 studies, 983 participants; RR 0.81, 95%CI 0.72-0.91, p=0.0003, NNT=9.1 (or 10)). In 10 studies (1441 participants) there were 6 deaths from a range of causes, 5 in participants assigned to LAAM (RR 2.28 (95%CI 0.59-8.9, p=0.2). other relevant outcomes, such as quality of life and criminal activity could not be analysed because of lack of information in the primary studies.

REVIEWER'S CONCLUSIONS

LAAM appears more effective than methadone at reducing heroin use. More LAAM patients than methadone ceased their allocated medication during the studies, but many transferred to methadone and so the significance of this is unclear. There was no difference in safety observed, although there was not enough evidence to comment on uncommon adverse events.

A risk-benefit analysis of methadone maintenance treatment

Methadone maintenance treatment for heroin (diamorphine) addiction has been extensively researched. There is consistent evidence that while in treatment, heroin addicts are at a lower risk of death, are less involved in crime, and feel and function better than while using heroin. Despite the research evidence supporting methadone treatment, there remains widespread public scepticism about this form of treatment. This scepticism is frequently expressed in terms of the perceived risks of methadone treatment. The perceived risk that methadone treatment may maintain people in an addicted lifestyle is not supported by research literature. The risks of treatment include an increased risk of death during induction into treatment, and risks of diversion of drugs to the black market. For some patients, adverse effects of methadone pose a problem and the availability of new pharmacotherapies may provide useful options for these patients. Risks can be reduced and benefits increased by directing greater attention to the quality of treatment.

Determination of l-alpha-acetylmethadol, l-alpha-noracetylmethadol and l-alpha-dinoracetylmethadol in plasma by gas chromatography-mass spectrometry

A method is described for the simultaneous determination of l-alpha-acetylmethadol (LAAM) and its N-demethylated metabolites, l-alpha-noracetylmethadol (norLAAM) and l-alpha-dinoracetylmethadol (dinorLAAM), in plasma by gas chromatography-chemical ionization mass spectrometry. Deuterated internal standards for each analyte serve as carriers and control for recovery during sample purification on a solid-phase extraction column (C18), and subsequent separation and analysis on a DB-17 capillary column. With this method, we have determined levels of LAAM, norLAAM, and dinorLAAM in small volumes of plasma (100 microliters). The limit of quantitation for all analytes was approximately 1.0 ng/g plasma and the limit of detection was approximately 0.5 ng/g plasma. An experimental application is also described where these analytes are quantitated in plasma obtained from rats before, during, and after chronic administration of LAAM-HCl. Since this technique affords a selective and sensitive means of detection of LAAM and its active, N-demethylated metabolites in small samples of blood, it may enable patient compliance to be more easily assessed by allowing samples to be collected by a simple finger-prick technique.

Heroin addiction: neurobiology, pharmacology, and policy

The neurobiology of drug addiction is being clarified. Research is revealing the anatomic pathways of primary drug reinforcement (reward) in the brain and the molecular architecture of the receptors on which addictive drugs act. All addictive drugs mimic (or occasionally block) the actions of some neurotransmitter; in the case of heroin or methadone an endogenous opioid, probably beta-endorphin. The groundwork is being laid for understanding Dole and Nyswander's "metabolic disease" concept as a concrete neurochemical abnormality of the endogenous opioid system. Thus, a stronger basis is developing for regarding methadone maintenance as a means of replacing a neurohormonal deficiency. Three practical conclusions that can be drawn from this model are: (1) methadone dosage must be adequate (never less than 50-80 mg); (2) it should be more widely accepted that some patients may require lifelong methadone maintenance; and (3) longer-acting, better stabilizing methadone congeners, such as LAAM and its metabolites, should be brought into general use.

Drug policy: striking the right balance

Drug policy should strike the right balance between reducing the harm done by psychoactive drugs and reducing the harm that results from strict legal prohibitions and their enforcement. It is concluded, from a cost-benefit analysis based on pharmacologic, toxicologic, sociologic, and historical facts, that radical steps to repeal the prohibitions on presently illicit drugs would be likely, on balance, to make matters worse rather than better. Specific recommendations are offered for ameliorating the dangers to users and to society that are posed by each addictive drug.

Naltrexone. A review of its pharmacodynamic and pharmacokinetic properties and therapeutic efficacy in the management of opioid dependence

Naltrexone is a long acting competitive antagonist at opioid receptors which blocks the subjective and objective responses produced by intravenous opioid challenge. It is suitable for oral administration, and has been studied as an adjunct for use in opioid addiction management programmes. In non-comparative clinical trials involving detoxified patients, oral naltrexone reduced heroin craving and between 23 and 62% of patients remained in treatment after 3 to 4 weeks. However, in two studies 32 to 58% of patients who continued in treatment were opioid-free between 6 and 12 months after stopping naltrexone. As might be expected studies involving highly motivated patients have shown this type of patient group to achieve greater treatment success rates during naltrexone therapy, and remain opioid-free longer than other groups of apparently less motivated patients. In addition, when naltrexone is combined with family support, psychotherapy and counselling, patients are more likely to remain opioid-free. Naltrexone produces a low incidence of side effects, with gastrointestinal effects being the most commonly reported symptoms. Thus, despite the overall high attrition rates from trials, in selected patient groups and in combination with appropriate support mechanisms and psychotherapy, naltrexone represents a useful adjunct for the maintenance of abstinence in the detoxified opioid addict.

Naltrexone treatment of heroin addiction: one-year follow-up

Pre-treatment characteristics and post-treatment outcome measures were compared for 40 patients who began naltrexone maintenance and 77 who did not after a 6-month period of temporary maintenance on L-alpha-acetylmethadol (methadyl acetate LAAM). Patients who chose to begin naltrexone were younger, had fewer incarcerations and fewer months incarcerated prior to LAAM treatment, had fewer opiate-free months following previous treatments, and were more likely to be of Caucasian ethnicity. One year later, significantly more patients who had received any naltrexone than those who had not were no longer in any treatment program and were opiate-free. We found no significant correlations between total duration of naltrexone-treatment and post-treatment outcome variables such as heroin use, arrests, incarcerations or enrollment in a treatment program.

(--)-alpha-Acetylmethadol effects on alcohol and diazepam use, sexual function and cardiac function

Selected behavioral and physiological effects of maintenance on (--)-alpha-acetylmethadol (LAAM) were examined for 67 men beginning LAAM maintenance. Thirty-four began LAAM maintenance after 1 month or more on methadone; 33 others were using street heroin immediately before beginning LAAM. Subjects were followed for 20 weeks on LAAM; assessment focused on changes in alcohol and diazepam use, sexual behavior and testicular function, and cardiovascular function. There was a trend toward increased alcoholism-related behaviors, but not consumption of alcohol, when on LAAM. Use of diazepam remained low. Subjects reported slightly enhanced sexual activity: reported number of ejaculations tended to increase, although interest in sexual activity remained constant. Semen volume values remained in the low normal range. In contrast to an earlier published report of reduced sperm motility in methadone and heroin users, normal motility was noted in this sample. The incidence of abnormal sperm morphology decreased from baseline to the end of the study. Cardiovascular function, as assessed by response to standard exercise, was unchanged during LAAM maintenance. Electrocardiograms revealed minor abnormalities prior to beginning LAAM maintenance; but these abnormalities did not consistently change during treatment. There is little evidence that the effects of LAAM maintenance differ from the effects of methadone maintenance on these behavioral and physiological functions.