Absence of antibody to human immunodeficiency virus in long-term, socially rehabilitated methadone maintenance patients.

Human immunodeficiency virus (HIV) infection has become widespread among parenteral drug abusers. We measured antibody to HIV and hepatitis B virus markers in 58 long-term, socially rehabilitated methadone-maintained former heroin addicts. None of the 58 had antibody to HIV, but one or more markers of hepatitis B virus infection were seen in 53 (91%). The duration of methadone maintenance was 16.9 +/- 0.5 years, and the median dose of methadone was 60 mg (range, 5 to 100 mg). Before methadone treatment, the patients had abused heroin parenterally for 10.3 +/- 1.7 years, and they had engaged in additional high-risk practices for HIV infection. We conclude that successful outcomes during methadone maintenance treatment are associated with sparing of parenteral drug abusers from HIV infection.

Methadone disposition in patients with chronic liver disease.

Chronic liver disease is common in methadone-maintained patients. We studied the disposition of this drug in 14 patients with biopsy-proved chronic liver disease and five otherwise healthy subjects receiving methadone maintenance treatment. The patients were divided into three groups based on the severity of liver disease, with group I having the most severe disease. The apparent terminal half-life of methadone was longer in group I than in group II and III (moderate and mild chronic liver disease, P less than 0.01) and the contrast group (P less than 0.05). All other kinetic indices determined for group I and all kinetic indices in groups II and III were essentially the same as those in the contrast subjects or in the other patient groups. Seven patients, including al five in group I, had flattened plasma methadone concentration-time curves. The data suggest that the maintenance dosage of methadone need not be changed in stable chronic liver disease.

Hepatitis C virus serology in parenteral drug users with chronic liver disease.

Chronic liver disease is a common complication of parenteral drug use, and liver cirrhosis is frequently seen in users of both parenteral drugs and alcohol. In 1978-83, we studied 88 parenteral drug users with sufficient evidence of chronic liver disease to warrant liver biopsy. Current alcohol abuse was noted in 63 (72%), and six (7%) were former alcohol abusers. Cirrhosis was found in 33 (38%). Hepatitis C antibody (anti-HCV) was detected in 86 (98%). Also, 40 of the anti-HCV positive sera were tested with recombinant immunoblot assay and all of these were reactive. All but one of the 31 patients with anti-HCV and cirrhosis were alcohol abusers. We conclude that parenteral drug users with chronic liver disease almost always have evidence of HCV infection.

Liver function tests in non-parenteral cocaine users.

To investigate the effect of cocaine on standard liver function tests (LFT), we studied 46 cocaine users with no history of parenteral drug use or homosexuality. LFT were similar in 21 users of cocaine only (Group A) and 25 users of cocaine and alcohol (Group B). Only three patients, two of whom were hepatitis B carriers, had an alanine aminotransferase level more than five units above normal limits. Group B patients were significantly more likely to complain of headaches, irritability, and loss of memory. We conclude that (1) non-parenteral cocaine use is rarely associated with significant LFT abnormalities and (2) alcohol may potentiate some adverse effects of cocaine.

Clinical and demographic features of patients admitted to a new chemical dependency program in New York City.

We reviewed the clinical and demographic features of all 128 patients who were admitted to a new 28-day in-patient chemical dependency program in New York City during the first six months of operation. The medical records were reviewed retrospectively. Alcohol, cocaine, heroin, marijuana and diazepam were the most common substances abused. Parenteral drug abuse at any time was reported by 51 (40%) of the 128 patients, and 42 (33%) were current parenteral drug abusers. Abusers of alcohol only were significantly older than parenteral drug abusers or non-parenteral drug abusers. Patients who were employed at admission had a significantly longer mean length of stay and a higher rate of completion of the program than those who were not employed. We conclude that: (1) parenteral drug abuse is likely to be commonly seen in chemical dependency programs serving middle-income patients in urban areas, (2) alcohol abusers are older than abusers of other drugs, (3) a higher educational level is associated with successful completion of the chemical dependency program, and (4) evaluation programs are needed in all types of chemical dependency treatment.

The medical status of methadone maintenance patients in treatment for 11-18 years.

To assess the safety and potential health consequences of long-term methadone maintenance treatment, we identified 111 male patients admitted to methadone maintenance treatment between 1965 and 1968, still enrolled in 1980 and in continuous treatment for at least 10 years. We were able, between 1980 and 1985, to examine patients or review records of 110 patients (99%). Most medical diagnoses, symptomatic complaints, physical examination findings and laboratory test results occurred with similar frequency in the long-term methadone maintenance patients and in a group of 56 long-term heroin addicts. These data suggest that prolonged methadone maintenance treatment is safe and is not associated with unexpected adverse effects.

The impact of hepatitis C virus infection on methadone maintenance treatment.

Hepatitis C virus infection is now recognized as a common and serious complication of injection drug use and will be encountered frequently in methadone maintenance patients. Approximately 1.8% of the United States population, or 3.9 million persons, are infected with hepatitis C virus. A majority of acute hepatitis C virus infections are associated with injection drug use, and 64-88% of injection drug users in seroprevalence studies have antibodies to hepatitis C. Hepatitis C virus infection is almost always chronic, and alcohol use increases the clinical severity. Therapy with interferon and ribavirin will induce long-term remission in up to 43% of patients with hepatitis C virus infection. Proper diagnosis and treatment of hepatitis C virus infection will be indicated for many patients in methadone programs and will require considerable resources.

Methadone medical maintenance (MMM): treating chronic opioid dependence in private medical practice--a summary report (1983-1998).

BACKGROUND: Methadone Medical Maintenance (MMM) was implemented in 1983 to enable socially rehabilitated methadone patients to be treated in the offices of private physicians rather than in the traditional clinic system. Over a period of 15 years, 158 methadone patients who fulfilled specific criteria within the clinic system entered this program in New York City. Participating patients reported to their physician once a month and received a one-month supply of methadone tablets rather than a one-day liquid dose in a bottle. METHOD: Of the 158 patients who entered this program, 132 (83.5%) were compliant with the regulations and proved to be treatable within the hospital-based private practices of internists participating in the program. Compliant MMM patients found it easier to improve their employment status and business situations, finish their educations, and normalize their lives in MMM as opposed to the traditional clinic system because they had simplified reporting schedules and fewer clinical restrictions. Twelve (8%) compliant patients were able to successfully withdraw from methadone after an average of 17.7 years of treatment in both the traditional clinics and MMM. Twenty compliant patients (13%) died from a variety of causes, 40% of which were related to cigarette smoking. None of the deaths were attributable to long-term methadone treatment. Other causes of death included hepatitis C, AIDS, cancer, homicide, complications of morbid obesity and meningitis. RESULTS: The 26 noncompliant patients (16.5%) were referred back to their clinics for continued treatment or were discharged for failure to report as directed. A major cause of failure in MMM was abuse of crack/cocaine. CONCLUSIONS: Stigma concerning enrollment in methadone treatment was a major social issue that patients faced. Many refused to inform employers, members of their families, friends, and other physicians who treated them for a various of conditions that they were methadone patients. The methadone medical maintenance physician, therefore, functions as a medical ombudsman for the patient, educating other physicians who treat the patient about methadone maintenance and its applicability to the patient. Our results can serve as a model for the expansion of office-based MMM treatment.

Medical maintenance: the treatment of chronic opiate dependence in general medical practice.

Medical maintenance was created to treat rehabilitated methadone maintenance patients within the context of general medical practice. One hundred methadone patients who met screening criteria were transferred for continuing care from traditional methadone clinics either to the practices of hospital-based physicians or to a health maintenance organization. Patients see their physicians about once per month, submit urine samples at the time of the office visits, drink a dose of methadone in the presence of their doctor or nurse, and receive a 28-day supply of methadone in pill or tablet form. The methadone prescriptions are filled by the hospital pharmacies. Physicians are responsible for the patients' annual physicals and can treat patients for other conditions. In our initial analysis of medical maintenance, 82.5% of the patients remained in good standing and 5% left the program voluntarily in good standing; the remaining 12.5% who were unable to respond favorably were returned to clinic programs. For rehabilitated patients requiring long-term or life-long care, medical maintenance is a viable alternative to traditional clinic programs. With proper policies and procedures, medical maintenance can be implemented in many hospitals.

Richard Lane: a tireless fighter for treatment of drug addiction.

After a long and courageous battle with cancer, Richard Lane died in 1994. He had been a long-term heroin addict and spent 12 years in prisons. After commencing treatment with methadone, he began to work with other addicts and helped to start Man Alive, the first methadone program in Baltimore. He later became Executive Director of Man Alive and a national leader in the effort to improve and expand methadone maintenance treatment. Among the innovations he promoted within the methadone program were on-site alcoholism treatment, protocols for poly-drug abuse, services for patients with acquired immune deficiency syndrome, improved pain management for methadone patients, and fewer restrictions for socially rehabilitated patients on methadone. He fought tirelessly for acceptance of methadone maintenance treatment by those in medicine, law enforcement, and politics. His accomplishments can inspire all in the addiction field to continue their efforts to improve the care of the addict.

Major medical problems and detoxification treatment of parenteral drug-abusing alcoholics.

Patients with combined addictive disease are frequently encountered in New York City. Three detoxification schedules have been developed which, alone or in combination, may be used for almost all substance abusers who require pharmacologic detoxification. Numerous factors contribute to pathogenesis of infections in parenteral drug-abusing alcoholics, including aspiration, impaired pulmonary function, immunologic abnormalities, and changes in endogenous microbial flora. The acquired immunodeficiency syndrome (AIDS) has recently emerged as a serious medical complication of parenteral substance abuse. Liver disease in parenteral drug-abusing alcoholics is also multifactorial. The direct hepatotoxic effects of alcohol, the adulterants of illicit, injectable drugs, and infections with the hepatitis B virus, non-A, non-B viruses, and the delta agent may all be contributing factors.

Abuse of antibiotics by abusers of parenteral heroin or cocaine.

We studied antibiotic intake in 197 abusers of alcohol, sedatives, or parenteral heroin or cocaine. Thirteen patients, all abusers of parenteral heroin or cocaine, had taken antibiotics without prescription, obtained from friends, from old prescriptions, or by purchase on the street. Past or present street purchase of antibiotics was noted in 27 patients and was more common (P less than .02) in parenteral substance abusers. Four parenteral substance abusers had infection or colonization with methicillin-resistant Staphylococcus aureus, and three of them had purchased antibiotics on the street before the present or a recent past hospitalization. Physicians treating abusers of parenteral heroin or cocaine should be aware that such patients may be taking antibiotics without medical supervision. This practice may be an important factor in the development and spread of methicillin-resistant S aureus.

Diminished responsiveness of homosexual men to antiviral therapy for HBsAg-positive chronic liver disease.

To identify factors predicting response to antiviral therapy, we reviewed the clinical features of 38 male hepatitis B surface antigen (HBsAg) carriers who received adenine arabinoside or lymphoblastoid interferon. All patients were followed for one year or longer. Response was defined as loss of hepatitis B e antigen, hepatitis B virus DNA and DNA polymerase from the serum. Only 2 of 19 (11%) homosexual men responded, compared with 10 of 19 (53%) heterosexual men (P less than 0.02). Both responders in the homosexual group had received lymphoblastoid interferon. None of the 13 homosexual men, but 8 of 16 heterosexual men, responded to adenine arabinoside or its monophosphate (P less than 0.01). Responders to antiviral therapy had higher (P less than 0.05) serum levels of aspartate aminotransferase (median 115, range 51-344) than did non-responders (median 83, range 32-181). The decreased responsiveness of homosexual men to antiviral therapy may be a result of more severe immunologic abnormalities in homosexual than in heterosexual men with HBsAg-positive chronic liver disease.

Acquired immunodeficiency syndrome and infection with hepatitis viruses in individuals abusing drugs by injection.

The abuse by injection of heroin or other drugs has long been associated with liver disease caused by hepatitis B virus (HBV) and other viruses. Increasingly severe hepatic and virological complications of parenteral drug abuse have been reported due to infection with new viruses or concomitant alcohol abuse. The hepatitis delta virus (HDV) can replicate and cause liver infection only in the presence of HBV; such infection in HBV carriers may cause rapidly progressive and clinically significant liver disease. Liver cirrhosis is frequently detected in parenteral drug abusers who have chronic infection with both HBV and HDV or who also abuse alcohol. More than one quarter of those persons with acquired immunodeficiency syndrome (AIDS) in the United States of America are homosexual or heterosexual males who are parenteral drug abusers. Existing evidence implicates parenteral drug abusers in the spread of hepatitis viruses and the retrovirus associated with AIDS to the general population. To cope with these serious problems the authors suggest that more intensive international co-operation is needed, particularly with a view to promoting data collection, research and the exchange of knowledge and experience on measures that have been effective in dealing with parenteral drug abuse and its complications.