Hi Henrik,
Thankyou for your very interesting reply. I found the two papers you attach about alcohol very useful..

I knew little about the Russian "social epidemic of alcoholism" apart from the newspaper headlines, and the discussion is of course relevent to our own local and national problem! For the last decade we have spent increasing amounts of money and time on the care of opiate/cocaine users, diverting money from the crimial justice system, as it was realised that helping this group reduces aquisitive crime. This year for the first time, the focus is moving back towards the much larger group whose lives are damaged or limited by alcohol. They also of course end up in prison at times, but often only overnight while they sober up.They are too busy drinking to be involved in much aquisitive crime, and  I think not so much has been made of the link between alcohol and violent crime so the criminal justice system has perhaps not been so interested in the past in contributing money from their budgets to "treatment" options for alcohol users.

In my GP surgery, which serves a population of 7000 inner city people, we have many more alcohol related deaths each year than drug related deaths. (I must do another audit!)  This month we will get an attached alcohol worker for the first time, to provide "brief interventions" (in 6-12 sessions)for those in the "harmful" group and signposting to another service offering detox etc, for the "hazardous and dependant" group. We started this year using the Audit C screening tool on all our new patients, and on those with chromic disease. Maybe in contrast to our readiness to prescribe methadone for opiate users, we are not prescribing much Antabuse (I have one patient only who is taking it and in fact it has helped him to rebuild his relationship and keep his employment and stay dry for the last 6 months.. an acheivement !! ) and we are so far only prescribing  small amounts of acamprosate and naltrexone this group. Maybe we will get more people into the abstinent group via the brief interventions and   will find some more takers for these pharmacological aids.

regards
judith yates
GP Birmingham UK

--- On Sat, 1/8/09, Henrik Thiesen <[log in to unmask]> wrote:

From: Henrik Thiesen <[log in to unmask]>
Subject: Re: [EFTC] Methadone and the Damage(??) Done
To: [log in to unmask]
Date: Saturday, 1 August, 2009, 5:20 PM

Hi Judith
 
I totally agree on what you write - what I don´t agree on is the simplistic idea that methadone is replacement for missing endorphine and that the treatment is long acting opioid. I have constantly about 20 patients on long-acting opioids. Increasing - decreasing and substituting.
The longest I have had in personal care is a 55 year old swedish gentleman who would have been long dead, homeless in the street of Copenhagen, as he was excluded from methadone treatment in sweden because he took illegal benzodiazepines. We have detoxed him from the benzoes which made his life quality very very much better - and he lives happily on a fixed dose of methadone which doesn´t move one millilitre up or down.
 
In Denmark we have given a very liberal access to methadone for years and if the idea of endorphine replacement was correct we would have seen people now on methadone, some on high doses, living without supplementary drug-use. We have had colleagues who has prescribed 5-600mg/day without any benefit for the patients who were still using heroin and whatever comes around.
 
What I do think is that the system you describe, with methadone as a part of treatment, will work - the problem as I have seen it is that because we have a political establishment which is scared of opioids we get a more and more politicised system which undermines treatment and more and more relies on "systems" that can be managed and measured.
 
Right now the system is denmark is almost destroyed by political decisions - what is left is more and more "managed care" where systems becomes more important than what comes out of it.
 
Some years ago the evidence base showed us that out-patient and in-patient treatment tended to have the "success-rate" - that led to a major movement of funding from in-patient to out-patient treatment. Nobody ever asked if there might be sub-groups who would benefit from in-patient treatment because it was "scientifically proven". Decisions are made by policy-makers, politicians and managers in the public system en the decisions tend to go in the direction that has the lowest cost. Once systems are dismantled they are not very easily re-built - and nobody really cares.
 
One of the cheap options is Methadone treatment with psycho-social care - It would not be cheap if psycho-social care was given but actually what is left after a few rounds of cost reduction is methadone given through a hole in a barred window (because violence has risen in syncronicity with cost reductions) and a very long and "scientific" intake process with endless talks with uneducated personnell doing endless ASI-scores.
 
So I´m absolutely not in any anti-methadone wing but if we do not know why we are giving medications and if social-workers and managers are the ones who in reality makes the diagnosing and in reality decides what treatment (inpatient -outpatient /methadone or anything else) the patient should receive before he´s seen by a doctor then things end up in a terrible mess.
 
We can hope as treatment providers, that we can help the person to change but as knowledge goes down and is replaced with schematic evidence base - all we do is locking people up in a fixed set of possibilities and at the same time we take away the possibility of self-care and re-creation of self.
 
The debate goes wrong - I think because methadone is linked with harm-reduction and in many places where methadone is not available it becomes "the marker" for introduction of a harm-reduction based system. But methadone is just a chemical substance and when used wrong it causes just as musch harm as any other inflexible use out of context. We have had a similar experience with Antabuse which we use to very large degree in Denmark ( http://www.nad.fi/pdf/50/Thiesen.pdf ) - when a medication becomes THE treatment - everything else seems to wither. Other examples could be the use of antidepressants and maybe upcoming - the use of ritaline for adult ADHD.
 
I haven´t read much in this thread that I disagree with because we all want to reduce harm for our patients.
 
All this doesn´t have much to do with alcohol - except... the Swedish does drink, sometimes a lot - sometimes nothing but it does not influence how much methadone he gets and we do not punish him for drinking.
 
Henrik
 
----- Original Message -----
From: [log in to unmask]" ymailto="mailto:[log in to unmask]" target="_blank" href="[log in to unmask]">Jude
To: [log in to unmask]" ymailto="mailto:[log in to unmask]" target="_blank" href="[log in to unmask]">[log in to unmask]
Sent: Saturday, August 01, 2009 3:15 PM
Subject: Re: [EFTC] Methadone and the Damage(??) Done

Hi,
I think i may well be a "Methadone Mullah", having prescribed it for thirty years as an inner city  GP. 

I find the high emotion involved in what seems to be an "anti-methadone" as much as a "pro-abstinence" debate, very surprising. 

I think back 30 years, to when my GP Trainer told me that people who use drugs to excess can be divided into " those who do it to get 'high' and those who do it to get 'by' " .

Those in the first group who find to their surprise, that they  are waking up shivering until they take heroin each morning,  will generally organise their own detox , with the help of family and friends, and most will of course succeed and get on with their lives, and some will write newspaper articles about their escape from heroin. 

For those in the second group, heroin is not their only problem, and they will not generally find it so simple, because when the cushion of heroin is taken away, the pain of their lives will return. They of course need a lot more psycho social help, but also will need time to pass while they build other ways to cope. 

This is the group helped by methadone or buprenorphine prescribed to replace the heroin, as unlike heroin, these are  both long acting medications, which last more than 24 hours, and so allow the person to wake in the morning without shivering and shaking, to raise their heads from the immediate physical daily need for heroin ,  while they regain their physical, social and psychological strength and well being.  

Eventually it is my experience that in many cases these people will feel able to plan a life without opiates. i have many patients who have taken ten or twenty years to reach this level of strength, but eventually they are delighted to escape from opiates (including methadone ) and get on with their lives. I certainly do my very best  encourage people registered at my surgery  on every occasion I see them,  to continue with life plans of every kind , while i continue to prescribe the maintenance methadone which gives them the time and space and strength to do that.  A daily heroin habit is of course a full time job, as funding, buying and using it generally leaves no room for anything else. 

Some of the damaged and struggling second group described above will need and will eventually benefit from the kind of help only offered within a "therapeutic community", and in the end that will of course be their route to a life without heroin However most of the  hundreds of thousands of people (in the UK alone) who find themselves dependent on heroin do not want or need to leave their own communities in order to get on with their lives, but they may well benefit from an interim period taking methadone . i cannot see why this is thought to be so bad. 

And then there is also the research evidence .....

all the best
Judith Yates 
GP Birmingham UK.  




On 28 Jul 2009, at 10:08, Henrik Thiesen wrote:

Hi Rowdy
 
You´re so right - calling methadone treatment "endorphine replacement" is in my opinion an absolutely faulty idea. In my opinion methadone or buprenorphine (or any other long-term opioid) can be used to give people addicted to opioids a break but over time things fall apart if nothing else is introduced. I have here in Denmark seen miserable "patients" on 3-400 mg´s of "endorphine replacement" so the replacement idea isn´t valid in my opinion.
 
The use of methadone has, when given freely and liberally as it is in my country, a tendency to make the system sloppy. Problems are taken care of with more methadone ("because his only problem is lack of endorphines") and benzoes and lack of systematic health and social care is covered in more methadone. The result often is devastating.
 
I have for 5 years been treating people who are "out of the system" which may mean that they get lots of methadone but no help beside that - and we can see that methadone helps a lot in the acute phase but after a while it is just another drug for many. I showed in my initial report on street-homeless drug users that the people with the most severe social- and health-problems were using just as many drugs if they were on methadone or not (and the Danish system does not exclude people who use drugs beside methadone so the endorphine replacement idea seems not to be valid here)
 
If methadone management were a true treatment - it would be replaced by opioid rotation as we see it in pain management and the surrounding psycho - social care would be upgraded. As it is now I it may end up with a system that tries to force metadone on non-opioid addicted people as I have seen it at several occations - simply because they don´t know what else to do.
 
Methadone is a drug among others in a complex treatment of a complex situation - it is not the treatment, except for those few that responds to methadone as an antidepressant - but they only need very little (5-10mg methadone or 2mg buprenorphine - which might be given as a patch)
 
A new report from our center for durg research underlines the faulty system - most users on long-term methadone feels lost in a system which has lost interest in them - as a frontline treatment provider we also see it as a lowered system-interest and lowered financial support for drug free treatment.
 
HenrikT (reviewer of the Danish Medicines List, Opioids and benzodiazepines)
----- Original Message -----
From: [log in to unmask]" ymailto="mailto:[log in to unmask]" target="_blank" href="[log in to unmask]">Rowdy Yates
To: [log in to unmask]" ymailto="mailto:[log in to unmask]" target="_blank" href="[log in to unmask]">[log in to unmask]
Sent: Saturday, July 25, 2009 12:32 PM
Subject: Re: [EFTC] Methadone and the Damage Done

Souraya

Hello - hope things are good in Lebanon. As for Neuberger's response. This is no big surprise. As far as I can see, any time that a study produces even a partially critical result on MMT some methadone mullah steps up to say (a) this is a flawed study or (b) the sample is atypical or (c) it's the practitioners' fault for not giving the "patients" enough methadone!

Draw your own conclusions on these desperate defences at a time when it would appear that the addiction business may again be slipping from the grip of the medical oligarchy!!


Rowdy Yates
Senior Research Fellow
Scottish Addiction Studies
University of Stirling



On 25 Jul 2009, at 10:05, "souraya frem" <[log in to unmask]">[log in to unmask]> wrote:

hello roudy
 
I just take that chance to send you my warmest regards to you and everyone on the list :)
 
just read the article you send and also had a look on the readers comment
any clarification on that matter
just in order to have a clear unswer regarding methadone definition & effectiveness
 
quoting for the reader's comment: 
 
"J.R. Neuberger | 21 Jul 09

These "results" fly in the face of decades of research in the US and point up no lacking in the effectiveness of methadone treatment, but instead illustrate the results attained when patients are chronically UNDERDOSED. At the proper dosage, methadone treatment results in longevity AND reduced illicit opiod usage. This study points up a serious flaw in how the treatment is being dispensed in the region specified and nothing more. Also, methadone is endorphin REPLACEMENT therapy and is a substitute for nothing. The use of this terminology itself points up possible prejudices on the part of the researchers of this piece. "Substitution" implies one drug being replaced with another. Methadone is, instead, a medical treatment for a medical condition--that condition being a damaged endorphin system in the brain which this therapy normalizes. It is endorphin replacement therapy and is both safe and effective at the proper daily dose. Kind regards, J.R. Neuberger National Alliance for Medication Assisted Recovery"

all the best
 
souraya
On Tue, Jul 21, 2009 at 11:22 AM, Rowdy Yates <[log in to unmask]">[log in to unmask]">[log in to unmask]> wrote:

This isn’t really about TCs but it is an interesting study showing that whilst long-term prescribing of methadone reduces mortality risks, it also increases the likelihood of continued injecting:


 

http://www.pulsetoday.co.uk/story.asp?sectioncode=23&storycode=4123296&c=1


 

Rowdy Yates 
Senior Research Fellow
Scottish Addiction Studies
Sociology, Social Policy & Criminology Section
Department of Applied Social Science
University of Stirling

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Academic Excellence at the Heart of Scotland.
The University of Stirling is a charity registered in Scotland, number SC 011159.