NYSDOH/AI The Role of Methadone in HIV Prevention And Treatment Sharon Stancliff, MD Medical Consultant AIDS Institute New York State Department of Health.

NYSDOH/AI

The Role of Methadone in HIV Prevention And Treatment

Sharon Stancliff, MDMedical ConsultantAIDS InstituteNew York StateDepartment of Health

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Drug Use and HIV

Injection of heroin and cocaine is the driving force behind HIV in New York State

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Addiction

• Opiates interact with receptors for endogenous peptides.

• Short term changes in the dopamine secreting neurons, such as atrophy are documented

• Long term changes are suspected.

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Genetics• Twin and adoption studies show a strong

familial trend in alcoholism

• Addictive disorders are common among the families of heroin addicts

• Anthenelli

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“Drug Addiction is a Brain Disease”

Alan Leshner, PhDNational Institute of Drug AbuseDirector

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National Institute of Health

“Methadone is the most effective treatment for heroin addiction.”National Institute of Health Consensus Development Conference on the Medical Treatment of Heroin Addiction

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Methadone

• A synthetic opiate with a 24-36 hour half-life

• Methadone Maintenance Treatment (MMT) was first implemented by Dole and Nyswander in the 1960s as most “detoxed” addicts relapsed to heroin use

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Methadone

• Usual effective dose: 80-120 mg range:5mg- >500 Clinical response guide dose

• Rettig, Leavitt

• 80-90% of those stopping MMT will return to heroin use so treatment is long term

• Ball, Magura

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Methadone

• Safe during pregnancy• Kandall

• No known long term detrimental effects• Novick

• MMT is usually accompanied by counseling and sometimes other requirements

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Benefits of Methadone Maintenance

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Reduction in Heroin Use

• Given a sufficient dose virtually all heroin users will stop using heroin

• At lesser doses heroin use is decreased.

• Ball 1991

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MMT patients are 3-6 times less likely to become HIV positive when compared to out-of-treatment heroin users.Metzger, Drucker, Gibson, Hartel

HIV Prevention

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Reduction in HIV seroconversion: a prospective study

• Comparison of opiate users in and out of methadone treatment

• Those out of treatment reported more risk behavior for HIV

• In treatment: 3.5% seroconverted, Out-of-treatment 22% seroconverted

• Metzger

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HIV positive heroin users on methadone are hospitalized less often and live longer than their counterparts who are not on methadone

Weber, Newschaffer, Laine

Improved outcome in HIV

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Other Benefits• A fourfold reduction in suicide

• A fourfold reduction in lethal overdose

• Capelhorn

• Reductions in sex work• Bellis

• Reduction in crime• Hubbard, Appel

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Issues in Methadone Prescribing

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Over regulation

• Available only in methadone clinics

• Frequent attendance required

• Limited number of slots

• Medical maintenance has been shown to be successful outside of these constraints

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Under Dosing

• A 1995 study of selected MMTPs found an average dose of less than 59mg

• 2/3s of the clinics set a dose ceiling of 80-100mgs

• D”Aunno

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Premature discharge

• A 1995 study found that the majority of clinics encourage detox after only 1 year of treatment

• Relapse can be deadly- Zanis found 8.2% mortality among 110 pts. leaving MMTP but only 1.2% among 397 remaining in treatment

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Misunderstandings about methadone

• Patients often believe that methadone causes bone or liver damage.

• Physicians may have misconceptions about pain management in methadone patients.

• It is also erroneously believed that MMT leads to cocaine use.

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MMT patients are judged by:

• Family

• Friends

• Physicians

• Social service providers

• Employers

• Politicians

• Drug users

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Stigmatization by drug Treatment Providers

• MMT patients are discouraged from speaking at Narcotics Anonymous meetings

• Narcotics Anonymous Bulletin

• Many facilities treating cocaine and alcohol abuse bar methadone

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Role of the Primary Care Provider

• Education of current and potential MMT patients and their families

• Understanding medical issues such as drug interactions

• Working with clinics to ensure the best possible care for patients

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Drug InteractionsDRUGS WHICH MAY LOWER

PLASMA LEVELS OF METHADONE

• Phenobarbital

• Carbamazepin (Tegretol)

• Phenytoin (Dilantin )**

• Ritonavir (Norvir)

** Major effect, may require large methadone dose increases

• Nevirapine (Viraimmune)**

• Rifampin**

• Efavirenz (Sustiva)**

• Abacavir (Ziagen)

• ethanol (chronic use)

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Drug Interactions II• DRUGS WHICH MAY INCREASE PLASMA LEVELS OF METHADONE

(none are major problems)

• Amitriptyline (Elavil)

• Cimetidine (Tagamet)

• Diazepam (Valium)

• Ethanol ( acute use)

• Ketoconazole (Nizoral)

• Zidovudine (AZT) levels may be increased by methadone.

• DRUGS WHICH ARE CONTRAINDICATED

• Pentazocine (Talwin),

• Tramadol (Ultram)

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For more HIV-related resources, please visit www.hivguidelines.org