[Ibogaine] Fw: Anniversary of methadone treatment for addiction. Untold savings in lives, suffering and spending.

tink tinkerbell.sarah at gmail.com
Fri Aug 12 12:50:25 EDT 2005


Ubiquitous constipation.
ROFLMAO!!!!!!!!!!!!!!!!!
love tink

On 8/12/05, Preston Peet <ptpeet at nyc.rr.com> wrote:
>  
> Oh boy, what a day for celebration, eh? 
>   
>   
> Peace and love,
> Preston Peet 
>   
> "Madness is not enlightenment, but the search for enlightenment is often
> mistaken for madness"
> Richard Davenport-Hines 
>   
> ptpeet at nyc.rr.com
> Editor http://www.drugwar.com
> Editor "Under the Influence- the Disinformation Guide to Drugs"
> Editor "Underground- The Disinformation Guide to Ancient Civilizations,
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> Etc.
>  
> ----- Original Message ----- 
> From: Andrew Byrne 
> To: ajbyrne at ozemail.com.au 
> Sent: Thursday, August 11, 2005 9:20 PM 
> Subject: Anniversary of methadone treatment for addiction. Untold savings in
> lives, suffering and spending. 
> 
>  
>  
> 
> Dear Readers, 
> 
>   
> 
> It is 40 years on 23rd August since the first report of methadone treatment
> for addiction.  Dole and Nyswander's seminal paper (below) is one of the
> most cited in the medical literature.  It stands as a model for all medical
> researchers, being a funded trial in a clinical research ward.  Although
> essentially a simple report of 24 Manhattan heroin addicts treated with a
> new intensive protocol utilising supervised oral daily methadone, it
> effectively defined the field for decades with its foresight and
> thoroughness.  Having only two early drop-outs, the 22 successful patients
> are described in detail, including hospital ward induction, average daily
> doses over 100mg, daily urine testing and, in addition to routine physical
> examinations, radio-iodine thyroid tests and bone marrow findings.  These
> pioneers also tested for physical coordination to determine safety at home
> and in the work place.  Patients were even given laxatives for the
> ubiquitous constipation.  
> 
>   
> 
> By 1970 Australian addicts were being offered similar treatment due to the
> frontier work of Dr Stella Dalton.  The treatment is now available in
> virtually every western country and is being introduced into some parts of
> the third world.  
> 
>   
> 
> The JAMA paper speaks for itself.  It remains a lasting tribute to its
> authors and acknowledged contributors: 
> 
>   
> 
> Published in Journal of the American Medical Association (JAMA) on 23 August
> 1965 
> 
>   
> 
> A Medical Treatment for Diacetylmorphine (Heroin) Addiction 
> 
>   
> 
> A Clinical Trial With Methadone Hydrochloride 
> 
>   
> 
> Vincent P. Dole, MD, and Marie Nyswander, MD 
> 
>   
> 
> A group of 22 patients, previously addicted to diacetylmorphine (heroin),
> have been stabilized with oral methadone hydrochloride. This medication
> appears to have two useful effects: (1) relief of narcotic hunger, and (2)
> induction of sufficient tolerance to block the euphoric effect of an average
> illegal dose of diacetylmorphine. With this medication, and a comprehensive
> program of rehabilitation, patients have shown marked improvement; they have
> returned to school, obtained jobs, and have become reconciled with their
> families. Medical and psychometric tests have disclosed no signs of
> toxicity, apart from constipation. This treatment requires careful medical
> supervision and many social services. In our opinion, both the medication
> and the supporting program are essential. 
> 
>   
> 
>   
> 
> The question of "maintenance treatment" of addicts is one that is often
> argued but seldom clearly defined. If this procedure is conceived as no more
> than an unsupervised distribution of narcotic drugs to addicts for
> self-administration of doses and at times of their choosing, then few
> physicians could accept it as proper medical practice. An uncontrolled
> supply of drugs would trap confirmed addicts in a closed world of drug
> taking, and tend to spread addiction. This procedure certainly would not
> qualify as "maintenance" in a medical sense. Uncontrolled distribution is
> mentioned here only to reject it, and to emphasize the distinction between
> distribution and medical prescription. The question at issue in the present
> study was whether a narcotic medicine, prescribed by physicians as part of a
> treatment program, could help in the return of addict patients to normal
> society. 
> 
>   
> 
> No definitive study of medical maintenance has yet been reported. The
> Council on Mental Health of the American Medical Association, after a
> thorough review of evidence available in 1957,1 concluded that "The
> advisability of establishing clinics or some equivalent system to dispense
> opiates to addicts cannot be settled on the basis of objective facts. Any
> position taken is necessarily based in part on opinion, and on this question
> opinions are divided." With respect to previous trials of maintenance
> treatment, the Council found that "Assessment of the operations of the
> narcotic dispensor between 1919 and 1923 is difficult because of the paucity
> of published material. Much of the small amount of data that is available is
> not sufficiently objective to be of great value in formulating any clear-cut
> opinion of the purpose of the clinics, the way in which they operated, or
> the results attained." No new studies bearing on the question of maintenance
> treatment have appeared in the eight years since this report was published.
> Meanwhile, various medical and legal committees have called for additional
> research.2,6 
> 
>   
> 
> See also page 673 ['Dependence on Barbiturates and Other Sedative Drugs'] 
> 
>   
> 
> The present study, conducted under the auspices of the departments of health
> and hospitals, New York city, has yielded encouraging results; patients who
> before treatment appeared hopelessly addicted are now engaged in useful
> occupations and are not using diacetylmorphine (heroin). As measured by
> social performance, these patients have ceased to be addicts. It must be
> emphasized that this paper is only a progress report, based on treatment of
> 22 patients for periods of 1 to 15 months. Such limited study obviously does
> not establish a new treatment for general application. The results, however,
> appear sufficiently promising to justify further trial of the procedure on a
> larger scale. 
> 
>   
> 
> Procedure 
> 
> The patients admitted to the program to date were men, aged 19 to 37,
> "mainline" diacetylmorphine users for several years with history of failure
> of withdrawal treatment. They have reported no substantial addictions to
> other agents (although most of them had used barbiturates or tranquilizers
> when narcotic drugs were unavailable), and they were not psychotic. Patients
> came from the streets, from drug withdrawal units, from referrals by social
> agencies and physicians who had heard of the program, and from recruitment
> of addicted friends by patients under treatment. Further details of their
> history are given in the Table. 
> 
>   
> 
> Division of Program Into Three Phases.—PHASE 1.—The addict patients were
> stabilized with methadone hydrochloride in an unlocked hospital ward, given
> a complete medical workup, psychiatric evaluation, a review of family and
> housing problems, and job-placement study. After the first week of they were
> free to leave the ward for school, libraries, shopping, and various
> amusements—usually, but not always, with one of the staff. Patients lacking
> a high school diploma started in classes that prepare students for a high
> school equivalency certificate. For the present study the time in this
> initial phase was arbitrarily set at six weeks. 
> 
>   
> 
> During this phase of hospitalization, the treatment unit was kept small
> (four to nine patients). This was felt necessary because most patients
> started the treatment with serious anxieties and doubts. The limitation of
> patient load allowed the staff to individualize the daily ward activities
> and deal with the special problems of each patient. 
> 
>   
> 
> PHASE 2.—This began when subjects left the hospital and became outpatients,
> returning every day for methadone medication. They were asked to drink their
> medication in the presence of a clinic nurse, and to leave a daily urine
> specimen for analysis. When indicated, this rule has been relaxed; reliable
> patients who have been on the program for several months have been given
> enough medication for a weekend at home or a short trip. Continued contact
> with the hospital staff was provided as required. The most important
> services needed during this phase of treatment were help in obtaining jobs,
> housing, and education. 
> 
>   
> 
> PHASE 3.—This phase is the goal of treatment, the stage in which an
> ex-addict has become a socially normal, self-supporting person. The two
> patients who are considered to have arrived at this phase are still
> receiving maintenance medication since the physicians in charge of their
> treatment feel that withdrawal at this time would be premature. Supervision
> of their medication is as careful as in phase 2; the only distinction
> between patients in phases 2 and 3 is in the degree of social advancement. 
> 
>   
> 
> PHASE 1A.—This phase designates a special group of four patients who are
> being maintained on high doses under close and continuing observation to
> reveal any delayed toxic effects of methadone (Table). So far, none have
> been found. These patients live on a metabolic ward, and so are still
> classified in phase 1, but as measured by social adjustment they have
> progressed to phase 2 or 3, since all are either employed or going to
> school. The ward serves mainly as their residence, which they are free to
> leave as they wish subject only to the general routine of hospital
> activities. 
> 
>   
> 
> Narcotic Medication.—Patients have differed markedly in tolerance to
> narcotics at the beginning of treatment, and in the rate with which they
> have adapted to increasing doses of medication. Individualization of
> treatment thus has been necessary. A rough estimate of initial tolerance was
> made from each new patient's history of drug usage, with allowance for
> exaggeration since addicts coming to a maintenance program usually fear that
> physicians will not prescribe enough medication, and with recognition of the
> fact that the number of "bags" used by an addict is not a reliable measure
> of narcotic tolerance. The diacetylmorphine content of a "bag" obtained on
> the street today is low and variable. This estimate provided a guide to
> initial dosage, but the only sure way to measure tolerance is to observe the
> reaction to test doses of narcotic drugs. The schedule, therefore, differed
> for each patient. 
> 
>   
> 
> On admission patients usually have shown mild or moderately severe symptoms
> of abstinence, the last shot of diacetylmorphine having been taken some
> hours before. These patients were relieved promptly by one or two doses of
> morphine sulfate (10 mg) or dihydromorphone (Dilaudid) hydrochloride (4 mg),
> given intramuscularly, and then started on oral methadone hydrochloride
> therapy (10 to 20 mg, twice daily). Patients coming to treatment without
> symptoms were started on a regimen of methadone without other medication,
> but were watched carefully for appearance of symptoms after admission. After
> the first 24 hours most patients could be maintained comfortably on the oral
> medication alone. The dose of methadone hydrochloride was increased
> gradually over the next four weeks to stabilization level (50 to 150 mg/
> day). Two patients in whom tolerance at the expected rate failed to develop
> have been held at lower doses (Table). With some patients, treated early in
> the study, the buildup of dosage was too rapid; they became overly sedated
> for a few days, and two of them had transient episodes of urinary retention
> and abdominal distention. Other patients, given too little, have become
> abstinent, exhibiting malaise, nausea, sweating, lacrimation, and
> restlessness. With more accurate prescription, patients have not become
> euphoric, sedated, or sick from abstinence at any stage of treatment. They
> have simply felt normal, and have not asked for more medication. 
> 
>   
> 
> After the patients reached maintenance level, the morning and evening doses
> were combined by progressive reduction of the evening medication with an
> equal addition to the methadone taken in the morning. After discharge from
> the hospital patients could thus be maintained by a single daily visit to
> the outpatient clinic. The patients who have had difficulty in spanning a
> 24-hour period with a single dose have been given medication to take at
> home; this has been a minor problem, limited to those who could visit the
> clinic only in the evening. In all cases it has been made clear to the
> patients (and accepted by them as a condition of treatment) that the amount
> of medication and the dosage schedule were the responsibility of the medical
> staff. Physicians did not discuss dosage with the patients, although of
> course they listened carefully to any report of symptoms that might suggest
> excess or lack of medication. 
> 
>   
> 
> Laboratory Control.—The urine of every patient was collected daily in the
> hospital and at each clinic visit, to be analyzed for methadone, morphine
> (the chief metabolite of diacetylmorphine), and quinine (a regular
> constituent of the street "bag"). The thin layer chromatographic method of
> Cochin and Daly7 was used, after preliminary extraction of the alkaloids
> from urine with cation exchange resin. The sensitivity of the procedure was
> such that it would give a definite positive if a patient had taken an
> average "bag" of diacetylmorphine during the preceding 24 hours. 
> 
>   
> 
> Results 
> 
> The most dramatic effect of this treatment has been the disappearance of
> narcotic hunger. All of the patients previously had made efforts to remain
> drug-free after withdrawal, but were unable to resist the craving. Drug
> hunger became intolerable for most of them shortly after discharge from
> withdrawal unit and return to their neighborhood. It became especially
> severe when they were exposed to emotional stress. With methadone
> maintenance, however, patients found that they could meet addict friends,
> and even watch them inject diacetylmorphine, without great difficulty. They
> have tolerated frustrating episodes without feeling a need for
> diacetylmorphine. They have stopped dreaming about drugs, and seldom talk
> about drugs when together. Patients have even become so indifferent to
> narcotics as to forget to take a scheduled dose of medication when busy at
> home. 
> 
>   
> 
> The extent to which the patients have ceased to behave as addicts, and their
> reliability in reporting illegal drug use, were verified by the results of
> urinanalysis. Negative results in almost all analyses showed that use of
> diacetylmorphine has been rare and sporadic, although the patients have had
> ample exposure to addict friends and pushers. Remarkably, the episodes of
> drug taking were reported by the patients spontaneously, and their reports
> have correlated with the laboratory evidence. 
> 
>   
> 
> An interesting phenomenon, which has been seen in several patients, was the
> production of symptoms typical of drug deficiency by acute emotional stress.
> Anxiety in some susceptible patients caused malaise, nausea, yawning, and
> sweating, indistinguishable from the effects of abstinence, even though the
> patients were being maintained on large doses of medication. After
> experiencing relief with reassurance but without additional medication,
> susceptible patients have become less alarmed by these symptoms, and the
> episodes have occurred less frequently. In two other patients symptoms
> suggesting abstinence have appeared in the course of mild respiratory-tract
> infections. These symptoms, not associated with anxiety, were difficult to
> evaluate, but in any event disappeared in a few days without need for
> increase in medication. These observations suggest that the effectiveness of
> methadone can vary with changes in psychological and metabolic state. 
> 
>   
> 
> The degree of tolerance established by methadone was titrated in six
> patients by giving diacetylmorphine, morphine, dilaudid, or methadone
> intravenously in a double-blind study. The drugs were given in randomized
> order and various doses six hours after the last administration of
> methadone. Stabilization with methadone, as here described, was found to
> make patients refractory to 40 to 80 mg diacetylmorphine (which would cost
> $10 to $25 if purchased on the street). Larger amounts were not
> systematically tested; probably blocking would extend to greater doses since
> two patients with high tolerance showed little reaction to intravenous
> injection of 200 mg of diacetylmorphine—a huge amount, possibly enough to
> kill a nontolerant individual. 
> 
>   
> 
> Unscheduled, but perhaps necessary, experiments in drug usage were made by
> four patients. These subjects found that they did not "get high" when
> "shooting" diacetylmorphine with addict friends on the street. Both the
> patients and their friends were astounded at their lack of reaction to the
> drug. They discontinued these unrewarding experiments without need for
> disciplinary measures, and have discouraged other patients from repeating
> the experiment. So long as patients take methadone as scheduled, they
> apparently cannot feel the euphoria of an addict taking a street bag of
> diacetylmorphine. 
> 
>   
> 
> Complications.—The chief medical problem has been constipation. The tonus of
> the sigmoid and the defecation reflex remain depressed even in patients with
> high tolerance to the narcotic effects of methadone, while the motility of
> the upper gastrointestinal tract appears to be unaffected. Five patients,
> given a barium sulfate meal and followed with daily x-ray examinations for a
> week, showed normal or only slightly delayed passage of barium through the
> small intestine, but in three of the five, the evacuation of barium from the
> colon was abnormally slow. Fecal impaction has occurred when patients have
> made no effort to defecate for several days. Patients therefore were
> instructed to take a hydrophilic colloid every day, and a supplementary
> laxative or enema if bowels have not moved for three days. With these
> precautions patients have had no further difficulty. 
> 
>   
> 
> Apart from constipation, patients have shown no major ill effects ascribable
> to use of methadone. The tendency of addicts to leukocytosis (9,000 to
> 14,000 white blood cells/cu mm with 60% to 80% polymorphonuclear cells10
> continued, apparently unaffected by this medication. Bone marrow biopsies in
> four patients after eight months of treatment were normal. No effect of
> methadone on renal function was disclosed by repeated urinanalyses.
> Liver-function tests, when originally normal, remained so. Results of basal
> metabolic rate, thyroid uptake of sodium iodide I 131, red blood cell uptake
> of labelled triiodothyronine, and plasma protein-bound iodine were normal in
> three patients who had been stabilized on methadone hydrochloride (100 to
> 150 mg/day) for four to six months. Some patients have reported excess
> sweating in hot weather, but no one has been unable to work for this reason.
> Mental and neuromuscular functions appear unaffected. Patients have
> performed well in school and at various jobs. Studies of motor skill
> (accuracy in tracking moving targets) showed normal coordination. We have
> not yet been able to find a medical or psychological test capable of
> distinguishing patients on methadone therapy from normal controls. They can,
> of course, be distinguished by urinanalysis. 
> 
> There has been no problem so far in holding patients. Only two of the
> patients who started treatment have been discharged. These uncooperative and
> disruptive psychopaths were transfered to withdrawal units. Two others who
> were admitted specifically for tolerance tests at an early stage of the
> study were returned (as originally planned) to the withdrawal unit from
> which they came; both subsequently have asked to return to the program. A
> fifth patient signed out after only four days on the ward, and also asked to
> return. 
> 
>   
> 
> Comment 
> 
> Previous efforts to treat addict patients with narcotic medication have been
> handicapped by lack of sufficiently long-acting agents. The Council's report
> noted that in 1919 to 1923 experience, "in all instances it was eventually
> found necessary to give drugs to addicts for self-administration." This is
> inherent in the pharmacology of parenterally administered morphine, which
> was used in these clinics and would probably apply to other agents with
> short periods of action such as diacetylmorphine, dihydromorphine, or
> meperidine. If addict patients are to be maintained with any of these drugs,
> they would need several injections per day; otherwise they would return to
> the street for additional drugs. 
> 
>   
> 
> Projected into large-scale treatment, a medical use of short-acting narcotic
> drugs would require dispensaries staffed to give thousands of injections per
> day, with rooms or park benches in the neighborhood for addicts to wait
> between shots. Alternatively, physicians would have to yield control of drug
> administration to the addicts themselves. Neither alternative is acceptable.
> With methadone, however, the situation is much different since patients can
> be stabilized with a single daily dose, taken orally, under medical control.
> Maintenance of patients with methadone is no more difficult than maintaining
> diabetics with oral hypoglycemic agents, and in both cases the patient
> should be able to live a normal life. 
> 
>   
> 
> We believe that methadone has contributed in an essential way to the
> favorable results, although it is quite clear that giving of medicine has
> been only part of the program. This drug appears to relieve narcotic hunger,
> and thus free the patient for other interests, as well as protect him
> against readdiction to diacetylmorphine by establishing a pharmacological
> block. A previous attempt by one of us (M.N.) to treat addict patients
> without narcotic medication ended in failure. Other clinics, attempting to
> rehabilitate patients after withdrawal, have had equally poor results.
> These, however, are indirect arguments. When the treatment program is
> sufficiently well established, the necessary control studies with social
> support, but without medication, must be made. 
> 
>   
> 
> This study was supported by the Health Research Council grant U-1501 of New
> York city, and by the National Association for Prevention of Addiction to
> Narcotics. 
> 
>   
> 
> Major contributions to this investigation were made by the following: Mary
> Jeanne Kreek, MD, bone marrow biopsies and tests of narcotic tolerance;
> Joyce Lowinson. MD. and George Lowen, MD, expansion of the program at
> Manhattan General Hospital; Nathan Poker, MD, measurements of intestinal
> motility; David Becker, MD, and Eugene Furth, MD. tests for thyroid
> function; and Norman Gordon, MD, Alan Warner, and Ann Henderson,
> measurements of motor skills of patients and ratings with intelligence tests
> and mood scales. 
> 
>   
> 
> Generic and Trade Names of Drug 
> 
> Sodium iodide I 131—Iodotope-1 131, Oriodide-131, Radiocaps131,
> Theriodide-131, Tracervial-131. 
> 
>   
> 
> References: 
> 
> 1. Council on Mental Health: Report on Narcotic Addiction, JAM/i
> 165:1707-1713 (Nov 30); 1834-1841 cDec 7 1968-1974 (Dec 14) 1957. 
> 
> 2. Joint Committee of American Bar Association and American Medical
> Association of Narcotic Drugs. Interim and Final Reports: Drug Addiction:
> Crime or Disease? Bloomington, MD: Indiana University Press, 1961. 
> 
> 3. Presidents Advisory Commission on Narcotic and Drug Abuse. Appendix 1.
> Final Report, US Government Printing Office. Nov 1963. 
> 
> 4. New York Academy of Medicine, Committee on Public Health: Report on Drug
> Addiction: II, Bull NY Aced Med 39:417-473 (July) 1963. 
> 
> 5. Eldridge, W.B.: Narcotics and Law, Chicago: American Bar Foundation,
> 1962. 
> 
> 6. National Council on Crime and Delinquency. Advisory Council of Judges.
> Narcotics Law Violations: Policy Statement, New York. 1964. 
> 
> 7. Cochin. J.. and Daly, ,J.: Rapid Identification of Analgesic Drugs in
> Urine With Thin-Layer Chromatography, Experientia 18:294-295 (June 15) 1962.
> 
> 8. Light. AB., and Torrance. E.G.: Opium Addiction: VI. Effects of Abrupt
> Withdrawal Followed by Readministration of Morphine in Human Addicts With
> Spectral Reference to Composition of Blood, Circulation, and Metabolism,
> Arch Intern Med 44:1-16 (July) 1929. 
> 
> 9. Ishell, H.. et al: Liability of Addiction of 6-Dimethylamino- 
> 
> 4.4-diphenyl-3-heptanone (Methadon, "Amidone" or "10820") in Man. Arch
> Intern Med 82:362-392 (Oct) 1948. 
> 
> 10. Berle, B., and Nyswander, M.: Ambulatory Withdrawal Treatment of Heroin
> Addicts, New York J Med 64:1846-1848 (July) 1964. 
> 
>   
> 
> Citation: 
> 
> Dole VP, Nyswander ME. A medical treatment for diacetylmorphine (heroin)
> addiction. J Amer Med Assoc 1965;193:646-50  
> 
>  
>  
> 
> Table 1. (legend) see attached xls file. 
> 
>   
> 
> Maintenance Therapy of Ex-Addicts With Methadone Hydrochloride, Summary of
> First 
> 
> 15 Months (February 1964 to May 1965). 
> 
>   
> 
> *For comparison with other treatment series, patients classified into three
> groups: Western European ancestry (E), Puerto Rican and Cuban (F), and Negro
> (N). 
> 
>   
> 
> ~ Age first used diacetylmorphine (FD); age at admission (A). 
> 
>   
> 
> ð Number of admissions to Federal Hospital—Lexington, Ky (F), state
> hospitals—Manhattan State, Central Islip (S), municipal hospital —Manhattan
> General, Metropolitan, Riverside (M), private clinics and groups, including
> Synanon (P). 
> 
>   
> 
> § All but two patients were employed at time of admission. Job indicated is
> best position ever held, 
> 
>   
> 
> Time in Army (A), Navy (N), Marines (M), or Air Force (AF). 
> 
>   
> 
> ¶ Dose methadone hydrochloride given orally, mg/day. 
> 
>   
> 
> # Phases of treatment: la—four patients, residents on metabolic ward of
> Rockefeller Institute; 1—new patients being stabilized on methadone therapy,
> they sleep in hospital but may leave during day for school, shopping, or
> job; 2—patients newly discharged, living at home or rooming house, needing
> social support; 3—ambulatory patients who are self-supporting. 
> 
>   
> 
> ** High school equivalency status: If not a high school graduate, each
> patient was encouraged to enroll in night school to prepare for high school
> equivalency certificate. Those who have completed this course, passed
> examination, and received certificate are indicated by 'Cert'; those now in
> night school indicated by NS." 
> 
>   
> 
>   
> 
> Posted by Andrew Byrne, Sydney addiction doctor. 
> 
>   
> 
>   
> 
>  
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