NYSDOH/AI The Role of Methadone in HIV Prevention And Treatment Sharon Stancliff, MD Medical...
-
Upload
felicia-potter -
Category
Documents
-
view
218 -
download
2
Transcript of NYSDOH/AI The Role of Methadone in HIV Prevention And Treatment Sharon Stancliff, MD Medical...
![Page 1: NYSDOH/AI The Role of Methadone in HIV Prevention And Treatment Sharon Stancliff, MD Medical Consultant AIDS Institute New York State Department of Health.](https://reader035.fdocuments.in/reader035/viewer/2022062515/56649f575503460f94c7bdbf/html5/thumbnails/1.jpg)
NYSDOH/AI
The Role of Methadone in HIV Prevention And Treatment
Sharon Stancliff, MDMedical ConsultantAIDS InstituteNew York StateDepartment of Health
![Page 2: NYSDOH/AI The Role of Methadone in HIV Prevention And Treatment Sharon Stancliff, MD Medical Consultant AIDS Institute New York State Department of Health.](https://reader035.fdocuments.in/reader035/viewer/2022062515/56649f575503460f94c7bdbf/html5/thumbnails/2.jpg)
NYSDOH/AI
Drug Use and HIV
Injection of heroin and cocaine is the driving force behind HIV in New York State
![Page 3: NYSDOH/AI The Role of Methadone in HIV Prevention And Treatment Sharon Stancliff, MD Medical Consultant AIDS Institute New York State Department of Health.](https://reader035.fdocuments.in/reader035/viewer/2022062515/56649f575503460f94c7bdbf/html5/thumbnails/3.jpg)
NYSDOH/AI
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.
![Page 4: NYSDOH/AI The Role of Methadone in HIV Prevention And Treatment Sharon Stancliff, MD Medical Consultant AIDS Institute New York State Department of Health.](https://reader035.fdocuments.in/reader035/viewer/2022062515/56649f575503460f94c7bdbf/html5/thumbnails/4.jpg)
NYSDOH/AI
Genetics• Twin and adoption studies show a strong
familial trend in alcoholism
• Addictive disorders are common among the families of heroin addicts
• Anthenelli
![Page 5: NYSDOH/AI The Role of Methadone in HIV Prevention And Treatment Sharon Stancliff, MD Medical Consultant AIDS Institute New York State Department of Health.](https://reader035.fdocuments.in/reader035/viewer/2022062515/56649f575503460f94c7bdbf/html5/thumbnails/5.jpg)
NYSDOH/AI
“Drug Addiction is a Brain Disease”
Alan Leshner, PhDNational Institute of Drug AbuseDirector
![Page 6: NYSDOH/AI The Role of Methadone in HIV Prevention And Treatment Sharon Stancliff, MD Medical Consultant AIDS Institute New York State Department of Health.](https://reader035.fdocuments.in/reader035/viewer/2022062515/56649f575503460f94c7bdbf/html5/thumbnails/6.jpg)
NYSDOH/AI
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
![Page 7: NYSDOH/AI The Role of Methadone in HIV Prevention And Treatment Sharon Stancliff, MD Medical Consultant AIDS Institute New York State Department of Health.](https://reader035.fdocuments.in/reader035/viewer/2022062515/56649f575503460f94c7bdbf/html5/thumbnails/7.jpg)
NYSDOH/AI
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
![Page 8: NYSDOH/AI The Role of Methadone in HIV Prevention And Treatment Sharon Stancliff, MD Medical Consultant AIDS Institute New York State Department of Health.](https://reader035.fdocuments.in/reader035/viewer/2022062515/56649f575503460f94c7bdbf/html5/thumbnails/8.jpg)
NYSDOH/AI
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
![Page 9: NYSDOH/AI The Role of Methadone in HIV Prevention And Treatment Sharon Stancliff, MD Medical Consultant AIDS Institute New York State Department of Health.](https://reader035.fdocuments.in/reader035/viewer/2022062515/56649f575503460f94c7bdbf/html5/thumbnails/9.jpg)
NYSDOH/AI
Methadone
• Safe during pregnancy• Kandall
• No known long term detrimental effects• Novick
• MMT is usually accompanied by counseling and sometimes other requirements
![Page 10: NYSDOH/AI The Role of Methadone in HIV Prevention And Treatment Sharon Stancliff, MD Medical Consultant AIDS Institute New York State Department of Health.](https://reader035.fdocuments.in/reader035/viewer/2022062515/56649f575503460f94c7bdbf/html5/thumbnails/10.jpg)
NYSDOH/AI
Benefits of Methadone Maintenance
![Page 11: NYSDOH/AI The Role of Methadone in HIV Prevention And Treatment Sharon Stancliff, MD Medical Consultant AIDS Institute New York State Department of Health.](https://reader035.fdocuments.in/reader035/viewer/2022062515/56649f575503460f94c7bdbf/html5/thumbnails/11.jpg)
NYSDOH/AI
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
![Page 12: NYSDOH/AI The Role of Methadone in HIV Prevention And Treatment Sharon Stancliff, MD Medical Consultant AIDS Institute New York State Department of Health.](https://reader035.fdocuments.in/reader035/viewer/2022062515/56649f575503460f94c7bdbf/html5/thumbnails/12.jpg)
NYSDOH/AI
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
![Page 13: NYSDOH/AI The Role of Methadone in HIV Prevention And Treatment Sharon Stancliff, MD Medical Consultant AIDS Institute New York State Department of Health.](https://reader035.fdocuments.in/reader035/viewer/2022062515/56649f575503460f94c7bdbf/html5/thumbnails/13.jpg)
NYSDOH/AI
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
![Page 14: NYSDOH/AI The Role of Methadone in HIV Prevention And Treatment Sharon Stancliff, MD Medical Consultant AIDS Institute New York State Department of Health.](https://reader035.fdocuments.in/reader035/viewer/2022062515/56649f575503460f94c7bdbf/html5/thumbnails/14.jpg)
NYSDOH/AI
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
![Page 15: NYSDOH/AI The Role of Methadone in HIV Prevention And Treatment Sharon Stancliff, MD Medical Consultant AIDS Institute New York State Department of Health.](https://reader035.fdocuments.in/reader035/viewer/2022062515/56649f575503460f94c7bdbf/html5/thumbnails/15.jpg)
NYSDOH/AI
Other Benefits• A fourfold reduction in suicide
• A fourfold reduction in lethal overdose
• Capelhorn
• Reductions in sex work• Bellis
• Reduction in crime• Hubbard, Appel
![Page 16: NYSDOH/AI The Role of Methadone in HIV Prevention And Treatment Sharon Stancliff, MD Medical Consultant AIDS Institute New York State Department of Health.](https://reader035.fdocuments.in/reader035/viewer/2022062515/56649f575503460f94c7bdbf/html5/thumbnails/16.jpg)
NYSDOH/AI
Issues in Methadone Prescribing
![Page 17: NYSDOH/AI The Role of Methadone in HIV Prevention And Treatment Sharon Stancliff, MD Medical Consultant AIDS Institute New York State Department of Health.](https://reader035.fdocuments.in/reader035/viewer/2022062515/56649f575503460f94c7bdbf/html5/thumbnails/17.jpg)
NYSDOH/AI
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
![Page 18: NYSDOH/AI The Role of Methadone in HIV Prevention And Treatment Sharon Stancliff, MD Medical Consultant AIDS Institute New York State Department of Health.](https://reader035.fdocuments.in/reader035/viewer/2022062515/56649f575503460f94c7bdbf/html5/thumbnails/18.jpg)
NYSDOH/AI
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
![Page 19: NYSDOH/AI The Role of Methadone in HIV Prevention And Treatment Sharon Stancliff, MD Medical Consultant AIDS Institute New York State Department of Health.](https://reader035.fdocuments.in/reader035/viewer/2022062515/56649f575503460f94c7bdbf/html5/thumbnails/19.jpg)
NYSDOH/AI
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
![Page 20: NYSDOH/AI The Role of Methadone in HIV Prevention And Treatment Sharon Stancliff, MD Medical Consultant AIDS Institute New York State Department of Health.](https://reader035.fdocuments.in/reader035/viewer/2022062515/56649f575503460f94c7bdbf/html5/thumbnails/20.jpg)
NYSDOH/AI
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.
![Page 21: NYSDOH/AI The Role of Methadone in HIV Prevention And Treatment Sharon Stancliff, MD Medical Consultant AIDS Institute New York State Department of Health.](https://reader035.fdocuments.in/reader035/viewer/2022062515/56649f575503460f94c7bdbf/html5/thumbnails/21.jpg)
NYSDOH/AI
MMT patients are judged by:
• Family
• Friends
• Physicians
• Social service providers
• Employers
• Politicians
• Drug users
![Page 22: NYSDOH/AI The Role of Methadone in HIV Prevention And Treatment Sharon Stancliff, MD Medical Consultant AIDS Institute New York State Department of Health.](https://reader035.fdocuments.in/reader035/viewer/2022062515/56649f575503460f94c7bdbf/html5/thumbnails/22.jpg)
NYSDOH/AI
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
![Page 23: NYSDOH/AI The Role of Methadone in HIV Prevention And Treatment Sharon Stancliff, MD Medical Consultant AIDS Institute New York State Department of Health.](https://reader035.fdocuments.in/reader035/viewer/2022062515/56649f575503460f94c7bdbf/html5/thumbnails/23.jpg)
NYSDOH/AI
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
![Page 24: NYSDOH/AI The Role of Methadone in HIV Prevention And Treatment Sharon Stancliff, MD Medical Consultant AIDS Institute New York State Department of Health.](https://reader035.fdocuments.in/reader035/viewer/2022062515/56649f575503460f94c7bdbf/html5/thumbnails/24.jpg)
NYSDOH/AI
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)
![Page 25: NYSDOH/AI The Role of Methadone in HIV Prevention And Treatment Sharon Stancliff, MD Medical Consultant AIDS Institute New York State Department of Health.](https://reader035.fdocuments.in/reader035/viewer/2022062515/56649f575503460f94c7bdbf/html5/thumbnails/25.jpg)
NYSDOH/AI
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)
![Page 26: NYSDOH/AI The Role of Methadone in HIV Prevention And Treatment Sharon Stancliff, MD Medical Consultant AIDS Institute New York State Department of Health.](https://reader035.fdocuments.in/reader035/viewer/2022062515/56649f575503460f94c7bdbf/html5/thumbnails/26.jpg)
NYSDOH/AI
For more HIV-related resources, please visit www.hivguidelines.org