The 2002 Official Patient's Sourcebook on Heroin Dependence: A Revised and Updated Directory for the Internet Age

THE 2002 OFFICIAL PATIENT’S SOURCEBOOK on HEROIN DEPENDENCE J AMES N. P ARKER , M.D. AND P HILIP M. P ARKER , P H .D...

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THE 2002 OFFICIAL PATIENT’S SOURCEBOOK

on

HEROIN

DEPENDENCE

J AMES N. P ARKER , M.D. AND P HILIP M. P ARKER , P H .D., E DITORS

ii

ICON Health Publications ICON Group International, Inc. 4370 La Jolla Village Drive, 4th Floor San Diego, CA 92122 USA Copyright Ó2002 by ICON Group International, Inc. Copyright Ó2002 by ICON Group International, Inc. All rights reserved. This book is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without written permission from the publisher. Printed in the United States of America. Last digit indicates print number: 10 9 8 7 6 4 5 3 2 1

Publisher, Health Care: Tiffany LaRochelle Editor(s): James Parker, M.D., Philip Parker, Ph.D. Publisher's note: The ideas, procedures, and suggestions contained in this book are not intended as a substitute for consultation with your physician. All matters regarding your health require medical supervision. As new medical or scientific information becomes available from academic and clinical research, recommended treatments and drug therapies may undergo changes. The authors, editors, and publisher have attempted to make the information in this book up to date and accurate in accord with accepted standards at the time of publication. The authors, editors, and publisher are not responsible for errors or omissions or for consequences from application of the book, and make no warranty, expressed or implied, in regard to the contents of this book. Any practice described in this book should be applied by the reader in accordance with professional standards of care used in regard to the unique circumstances that may apply in each situation, in close consultation with a qualified physician. The reader is advised to always check product information (package inserts) for changes and new information regarding dose and contraindications before taking any drug or pharmacological product. Caution is especially urged when using new or infrequently ordered drugs, herbal remedies, vitamins and supplements, alternative therapies, complementary therapies and medicines, and integrative medical treatments. Cataloging-in-Publication Data Parker, James N., 1961Parker, Philip M., 1960The 2002 Official Patient’s Sourcebook on Heroin Dependence: Revised and Updated for the Internet Age/James N. Parker and Philip M. Parker, editors p. cm. Includes bibliographical references, glossary and index. ISBN: 0-597-83242-0 1. Heroin Dependence-Popular works. I. Title.

iii

Disclaimer This publication is not intended to be used for the diagnosis or treatment of a health problem or as a substitute for consultation with licensed medical professionals. It is sold with the understanding that the publisher, editors, and authors are not engaging in the rendering of medical, psychological, financial, legal, or other professional services. References to any entity, product, service, or source of information that may be contained in this publication should not be considered an endorsement, either direct or implied, by the publisher, editors or authors. ICON Group International, Inc., the editors, or the authors are not responsible for the content of any Web pages nor publications referenced in this publication.

Copyright Notice If a physician wishes to copy limited passages from this sourcebook for patient use, this right is automatically granted without written permission from ICON Group International, Inc. (ICON Group). However, all of ICON Group publications are copyrighted. With exception to the above, copying our publications in whole or in part, for whatever reason, is a violation of copyright laws and can lead to penalties and fines. Should you want to copy tables, graphs or other materials, please contact us to request permission (e-mail: [email protected]). ICON Group often grants permission for very limited reproduction of our publications for internal use, press releases, and academic research. Such reproduction requires confirmed permission from ICON Group International Inc. The disclaimer above must accompany all reproductions, in whole or in part, of this sourcebook.

iv

Dedication To the healthcare professionals dedicating their time and efforts to the study of heroin dependence.

Acknowledgements The collective knowledge generated from academic and applied research summarized in various references has been critical in the creation of this sourcebook which is best viewed as a comprehensive compilation and collection of information prepared by various official agencies which directly or indirectly are dedicated to heroin dependence. All of the Official Patient’s Sourcebooks draw from various agencies and institutions associated with the United States Department of Health and Human Services, and in particular, the Office of the Secretary of Health and Human Services (OS), the Administration for Children and Families (ACF), the Administration on Aging (AOA), the Agency for Healthcare Research and Quality (AHRQ), the Agency for Toxic Substances and Disease Registry (ATSDR), the Centers for Disease Control and Prevention (CDC), the Food and Drug Administration (FDA), the Healthcare Financing Administration (HCFA), the Health Resources and Services Administration (HRSA), the Indian Health Service (IHS), the institutions of the National Institutes of Health (NIH), the Program Support Center (PSC), and the Substance Abuse and Mental Health Services Administration (SAMHSA). In addition to these sources, information gathered from the National Library of Medicine, the United States Patent Office, the European Union, and their related organizations has been invaluable in the creation of this sourcebook. Some of the work represented was financially supported by the Research and Development Committee at INSEAD. This support is gratefully acknowledged. Finally, special thanks are owed to Tiffany LaRochelle for her excellent editorial support.

v

About the Editors James N. Parker, M.D. Dr. James N. Parker received his Bachelor of Science degree in Psychobiology from the University of California, Riverside and his M.D. from the University of California, San Diego. In addition to authoring numerous research publications, he has lectured at various academic institutions. Dr. Parker is the medical editor for the Official Patient’s Sourcebook series published by ICON Health Publications.

Philip M. Parker, Ph.D. Philip M. Parker is the Eli Lilly Chair Professor of Innovation, Business and Society at INSEAD (Fontainebleau, France and Singapore). Dr. Parker has also been Professor at the University of California, San Diego and has taught courses at Harvard University, the Hong Kong University of Science and Technology, the Massachusetts Institute of Technology, Stanford University, and UCLA. Dr. Parker is the associate editor for the Official Patient’s Sourcebook series published by ICON Health Publications.

vi

About ICON Health Publications In addition to heroin dependence, Official Patient’s Sourcebooks are available for the following related topics: ·

The Official Patient's Sourcebook on Alcoholism

·

The Official Patient's Sourcebook on Anabolic Steroid Dependence

·

The Official Patient's Sourcebook on Club Drug Dependence

·

The Official Patient's Sourcebook on Cocaine Dependence

·

The Official Patient's Sourcebook on Dextromethorphan Dependence

·

The Official Patient's Sourcebook on Dissociative Drug Dependence

·

The Official Patient's Sourcebook on Ghb Dependence

·

The Official Patient's Sourcebook on Hepatitis C

·

The Official Patient's Sourcebook on Inhalants Dependence

·

The Official Patient's Sourcebook on Ketamine Dependence

·

The Official Patient's Sourcebook on Lsd Dependence

·

The Official Patient's Sourcebook on Marijuana Dependence

·

The Official Patient's Sourcebook on Mdma Dependence

·

The Official Patient's Sourcebook on Methamphetamine Dependence

·

The Official Patient's Sourcebook on Nicotine Dependence

·

The Official Patient's Sourcebook on Pcp Dependence

·

The Official Patient's Sourcebook on Prescription Cns Depressants Dependence

·

The Official Patient's Sourcebook on Prescription Drug Dependence

·

The Official Patient's Sourcebook on Prescription Opioids Dendedence

·

The Official Patient's Sourcebook on Prescription Stimulants Dependence

·

The Official Patient's Sourcebook on Rohypnol Dependence

To discover more about ICON Health Publications, simply check with your preferred online booksellers, including Barnes & Noble.com and Amazon.com which currently carry all of our titles. Or, feel free to contact us directly for bulk purchases or institutional discounts: ICON Group International, Inc. 4370 La Jolla Village Drive, Fourth Floor San Diego, CA 92122 USA Fax: 858-546-4341 Web site: www.icongrouponline.com/health

Contents vii

Table of Contents INTRODUCTION ................................................................................................................................. 1 Overview ....................................................................................................................................... 1 Organization ................................................................................................................................. 3 Scope.............................................................................................................................................. 3 Moving Forward............................................................................................................................ 4 PART I: THE ESSENTIALS ............................................................................................................. 7 CHAPTER 1. THE ESSENTIALS ON HEROIN DEPENDENCE: GUIDELINES ......................................... 9 Overview ....................................................................................................................................... 9 What Is Heroin? .......................................................................................................................... 12 What Is the Scope of Heroin Use in the United States? .............................................................. 12 How Is Heroin Used? .................................................................................................................. 13 What Are the Immediate (Short-Term) Effects of Heroin Use? .................................................. 14 What Are the Long-Term Effects of Heroin Use? ....................................................................... 15 What Are the Medical Complications of Chronic Heroin Use? .................................................. 17 What Are the Treatments for Heroin Addiction?........................................................................ 18 What Are the Opioid Analogs and Their Dangers? .................................................................... 20 Heroin INFOFAX ....................................................................................................................... 21 Health Hazards............................................................................................................................ 21 Tolerance, Addiction, and Withdrawal ....................................................................................... 22 Treatment .................................................................................................................................... 23 Extent of Use ............................................................................................................................... 24 NIH Consensus Statement on Opiate Addiction Treatment....................................................... 25 What Are Treatments for Opiate Addiction?.............................................................................. 27 Is Opiate Dependence a Medical Disorder? ................................................................................ 30 Consequences of Untreated Opiate Dependence.......................................................................... 33 Current Treatment Modalities .................................................................................................... 35 Barriers to Effective Use of Opiate Agonists ............................................................................... 38 Future Research Areas................................................................................................................. 40 Conclusions and Recommendations ............................................................................................ 42 More Guideline Sources .............................................................................................................. 42 Vocabulary Builder...................................................................................................................... 46 CHAPTER 2. SEEKING GUIDANCE ................................................................................................... 53 Overview ..................................................................................................................................... 53 Associations and Heroin Dependence ......................................................................................... 53 Finding Drug Treatment and Alcohol Abuse Treatment Programs ........................................... 55 Finding Doctors........................................................................................................................... 57 Selecting Your Doctor ................................................................................................................. 58 Working with Your Doctor ......................................................................................................... 59 Broader Health-Related Resources .............................................................................................. 60 CHAPTER 3. CLINICAL TRIALS AND HEROIN DEPENDENCE ......................................................... 61 Overview ..................................................................................................................................... 61 Recent Trials on Heroin Dependence .......................................................................................... 64 Benefits and Risks........................................................................................................................ 72 Keeping Current on Clinical Trials ............................................................................................. 75 General References....................................................................................................................... 76 Vocabulary Builder...................................................................................................................... 77 PART II: ADDITIONAL RESOURCES AND ADVANCED MATERIAL ........................... 79 CHAPTER 4. STUDIES ON HEROIN DEPENDENCE ........................................................................... 81 Overview ..................................................................................................................................... 81

viii Contents

Federally-Funded Research on Heroin Dependence .................................................................... 81 E-Journals: PubMed Central ....................................................................................................... 90 The National Library of Medicine: PubMed................................................................................ 90 Vocabulary Builder...................................................................................................................... 91 CHAPTER 5. BOOKS ON HEROIN DEPENDENCE ............................................................................. 95 Overview ..................................................................................................................................... 95 Book Summaries: Federal Agencies ............................................................................................. 95 Book Summaries: Online Booksellers .......................................................................................... 97 The National Library of Medicine Book Index........................................................................... 101 Chapters on Heroin Dependence ............................................................................................... 105 General Home References .......................................................................................................... 105 Vocabulary Builder.................................................................................................................... 106 CHAPTER 6. MULTIMEDIA ON HEROIN DEPENDENCE ................................................................ 107 Overview ................................................................................................................................... 107 Bibliography: Multimedia on Heroin Dependence .................................................................... 107 Vocabulary Builder.................................................................................................................... 109 CHAPTER 7. PHYSICIAN GUIDELINES AND DATABASES .............................................................. 111 Overview ................................................................................................................................... 111 NIH Guidelines ......................................................................................................................... 111 NIH Databases .......................................................................................................................... 112 Other Commercial Databases .................................................................................................... 116 The Genome Project and Heroin Dependence ........................................................................... 117 Specialized References ............................................................................................................... 121 Vocabulary Builder.................................................................................................................... 122 PART III. APPENDICES .............................................................................................................. 123 APPENDIX A. RESEARCHING YOUR MEDICATIONS ..................................................................... 125 Overview ................................................................................................................................... 125 Your Medications: The Basics ................................................................................................... 125 Learning More about Your Medications ................................................................................... 127 Commercial Databases............................................................................................................... 128 Contraindications and Interactions (Hidden Dangers)............................................................. 130 A Final Warning ....................................................................................................................... 131 General References..................................................................................................................... 131 Vocabulary Builder.................................................................................................................... 132 APPENDIX B. RESEARCHING ALTERNATIVE MEDICINE ............................................................... 133 Overview ................................................................................................................................... 133 What Is CAM? .......................................................................................................................... 133 What Are the Domains of Alternative Medicine? ..................................................................... 134 Can Alternatives Affect My Treatment?................................................................................... 137 Finding CAM References on Heroin Dependence..................................................................... 138 Additional Web Resources......................................................................................................... 144 General References..................................................................................................................... 145 APPENDIX C. RESEARCHING NUTRITION..................................................................................... 147 Overview ................................................................................................................................... 147 Food and Nutrition: General Principles .................................................................................... 147 Finding Studies on Heroin Dependence.................................................................................... 152 Federal Resources on Nutrition................................................................................................. 156 Additional Web Resources......................................................................................................... 156 Vocabulary Builder.................................................................................................................... 157 APPENDIX D. FINDING MEDICAL LIBRARIES ............................................................................... 159 Overview ................................................................................................................................... 159 Preparation ................................................................................................................................ 159 Finding a Local Medical Library ............................................................................................... 160

Contents

ix

Medical Libraries Open to the Public ........................................................................................ 160 APPENDIX E. PRINCIPLES OF DRUG ADDICTION TREATMENT .................................................... 167 Overview ................................................................................................................................... 167 Principles of Effective Treatment .............................................................................................. 167 What Is Drug Addiction?.......................................................................................................... 170 Frequently Asked Questions ..................................................................................................... 171 Drug Addiction Treatment in the United States ...................................................................... 178 General Categories of Treatment Programs .............................................................................. 179 Treating Criminal Justice-Involved Drug Abusers and Addicts .............................................. 182 Scientifically-Based Approaches to Drug Addiction Treatment ............................................... 183 Resources ................................................................................................................................... 191 Selected NIDA Educational Resources on Drug Addiction Treatment .................................... 191 Vocabulary Builder.................................................................................................................... 195 ONLINE GLOSSARIES ............................................................................................................... 197 Online Dictionary Directories................................................................................................... 200 HEROIN DEPENDENCE GLOSSARY...................................................................................... 201 General Dictionaries and Glossaries ......................................................................................... 211 INDEX.............................................................................................................................................. 213

Introduction

1

INTRODUCTION Overview Dr. C. Everett Koop, former U.S. Surgeon General, once said, “The best prescription is knowledge.”1 The Agency for Healthcare Research and Quality (AHRQ) of the National Institutes of Health (NIH) echoes this view and recommends that every patient incorporate education into the treatment process. According to the AHRQ: Finding out more about your condition is a good place to start. By contacting groups that support your condition, visiting your local library, and searching on the Internet, you can find good information to help guide your treatment decisions. Some information may be hard to find—especially if you don't know where to look.2 As the AHRQ mentions, finding the right information is not an obvious task. Though many physicians and public officials had thought that the emergence of the Internet would do much to assist patients in obtaining reliable information, in March 2001 the National Institutes of Health issued the following warning: The number of Web sites offering health-related resources grows every day. Many sites provide valuable information, while others may have information that is unreliable or misleading.3

Quotation from http://www.drkoop.com. The Agency for Healthcare Research and Quality (AHRQ): http://www.ahcpr.gov/consumer/diaginfo.htm. 3 From the NIH, National Cancer Institute (NCI): http://cancertrials.nci.nih.gov/beyond/evaluating.html. 1 2

2

Heroin Dependence

Since the late 1990s, physicians have seen a general increase in patient Internet usage rates. Patients frequently enter their doctor's offices with printed Web pages of home remedies in the guise of latest medical research. This scenario is so common that doctors often spend more time dispelling misleading information than guiding patients through sound therapies. The Official Patient’s Sourcebook on Heroin Dependence has been created for patients who have decided to make education and research an integral part of the treatment process. The pages that follow will tell you where and how to look for information covering virtually all topics related to heroin dependence, from the essentials to the most advanced areas of research. The title of this book includes the word “official.” This reflects the fact that the sourcebook draws from public, academic, government, and peerreviewed research. Selected readings from various agencies are reproduced to give you some of the latest official information available to date on heroin dependence. Given patients’ increasing sophistication in using the Internet, abundant references to reliable Internet-based resources are provided throughout this sourcebook. Where possible, guidance is provided on how to obtain free-ofcharge, primary research results as well as more detailed information via the Internet. E-book and electronic versions of this sourcebook are fully interactive with each of the Internet sites mentioned (clicking on a hyperlink automatically opens your browser to the site indicated). Hard copy users of this sourcebook can type cited Web addresses directly into their browsers to obtain access to the corresponding sites. Since we are working with ICON Health Publications, hard copy Sourcebooks are frequently updated and printed on demand to ensure that the information provided is current. In addition to extensive references accessible via the Internet, every chapter presents a “Vocabulary Builder.” Many health guides offer glossaries of technical or uncommon terms in an appendix. In editing this sourcebook, we have decided to place a smaller glossary within each chapter that covers terms used in that chapter. Given the technical nature of some chapters, you may need to revisit many sections. Building one’s vocabulary of medical terms in such a gradual manner has been shown to improve the learning process. We must emphasize that no sourcebook on heroin dependence should affirm that a specific diagnostic procedure or treatment discussed in a research study, patent, or doctoral dissertation is “correct” or your best option. This sourcebook is no exception. Each patient is unique. Deciding on appropriate

Introduction

3

options is always up to the patient in consultation with their physician and healthcare providers.

Organization This sourcebook is organized into three parts. Part I explores basic techniques to researching heroin dependence (e.g. finding guidelines on diagnosis, treatments, and prognosis), followed by a number of topics, including information on how to get in touch with organizations, associations, or other patient networks dedicated to heroin dependence. It also gives you sources of information that can help you find a doctor in your local area specializing in treating heroin dependence. Collectively, the material presented in Part I is a complete primer on basic research topics for patients with heroin dependence. Part II moves on to advanced research dedicated to heroin dependence. Part II is intended for those willing to invest many hours of hard work and study. It is here that we direct you to the latest scientific and applied research on heroin dependence. When possible, contact names, links via the Internet, and summaries are provided. It is in Part II where the vocabulary process becomes important as authors publishing advanced research frequently use highly specialized language. In general, every attempt is made to recommend “free-to-use” options. Part III provides appendices of useful background reading for all patients with heroin dependence or related disorders. The appendices are dedicated to more pragmatic issues faced by many patients with heroin dependence. Accessing materials via medical libraries may be the only option for some readers, so a guide is provided for finding local medical libraries which are open to the public. Part III, therefore, focuses on advice that goes beyond the biological and scientific issues facing patients with heroin dependence.

Scope While this sourcebook covers heroin dependence, your doctor, research publications, and specialists may refer to your condition using a variety of terms. Therefore, you should understand that heroin dependence is often considered a synonym or a condition closely related to the following: ·

Heroin

·

Heroin Abuse

4

Heroin Dependence

·

Heroin Addiction

·

Heroin Overdose

In addition to synonyms and related conditions, physicians may refer to heroin dependence using certain coding systems. The International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) is the most commonly used system of classification for the world's illnesses. Your physician may use this coding system as an administrative or tracking tool. The following classification is commonly used for heroin dependence:4 ·

304.0 opioid type dependence, heroin

·

305.5 opioid abuse

For the purposes of this sourcebook, we have attempted to be as inclusive as possible, looking for official information for all of the synonyms relevant to heroin dependence. You may find it useful to refer to synonyms when accessing databases or interacting with healthcare professionals and medical librarians.

Moving Forward Since the 1980s, the world has seen a proliferation of healthcare guides covering most illnesses. Some are written by patients or their family members. These generally take a layperson's approach to understanding and coping with an illness or disorder. They can be uplifting, encouraging, and highly supportive. Other guides are authored by physicians or other healthcare providers who have a more clinical outlook. Each of these two styles of guide has its purpose and can be quite useful. As editors, we have chosen a third route. We have chosen to expose you to as many sources of official and peer-reviewed information as practical, for the purpose of educating you about basic and advanced knowledge as recognized by medical science today. You can think of this sourcebook as your personal Internet age reference librarian.

4 This list is based on the official version of the World Health Organization's 9th Revision, International Classification of Diseases (ICD-9). According to the National Technical Information Service, “ICD-9CM extensions, interpretations, modifications, addenda, or errata other than those approved by the U.S. Public Health Service and the Health Care Financing Administration are not to be considered official and should not be utilized. Continuous maintenance of the ICD-9-CM is the responsibility of the federal government.”

Introduction

5

Why “Internet age”? All too often, patients diagnosed with heroin dependence will log on to the Internet, type words into a search engine, and receive several Web site listings which are mostly irrelevant or redundant. These patients are left to wonder where the relevant information is, and how to obtain it. Since only the smallest fraction of information dealing with heroin dependence is even indexed in search engines, a non-systematic approach often leads to frustration and disappointment. With this sourcebook, we hope to direct you to the information you need that you would not likely find using popular Web directories. Beyond Web listings, in many cases we will reproduce brief summaries or abstracts of available reference materials. These abstracts often contain distilled information on topics of discussion. While we focus on the more scientific aspects of heroin dependence, there is, of course, the emotional side to consider. Later in the sourcebook, we provide a chapter dedicated to helping you find peer groups and associations that can provide additional support beyond research produced by medical science. We hope that the choices we have made give you the most options available in moving forward. In this way, we wish you the best in your efforts to incorporate this educational approach into your treatment plan. The Editors

7

PART I: THE ESSENTIALS

ABOUT PART I Part I has been edited to give you access to what we feel are “the essentials” on heroin dependence. The essentials of a disease typically include the definition or description of the disease, a discussion of who it affects, the signs or symptoms associated with the disease, tests or diagnostic procedures that might be specific to the disease, and treatments for the disease. Your doctor or healthcare provider may have already explained the essentials of heroin dependence to you or even given you a pamphlet or brochure describing heroin dependence. Now you are searching for more indepth information. As editors, we have decided, nevertheless, to include a discussion on where to find essential information that can complement what your doctor has already told you. In this section we recommend a process, not a particular Web site or reference book. The process ensures that, as you search the Web, you gain background information in such a way as to maximize your understanding.

Guidelines

9

CHAPTER 1. THE ESSENTIALS ON HEROIN DEPENDENCE: GUIDELINES Overview Official agencies, as well as federally-funded institutions supported by national grants, frequently publish a variety of guidelines on heroin dependence. These are typically called “Fact Sheets” or “Guidelines.” They can take the form of a brochure, information kit, pamphlet, or flyer. Often they are only a few pages in length. The great advantage of guidelines over other sources is that they are often written with the patient in mind. Since new guidelines on heroin dependence can appear at any moment and be published by a number of sources, the best approach to finding guidelines is to systematically scan the Internet-based services that post them.

The National Institutes of Health (NIH)5 The National Institutes of Health (NIH) is the first place to search for relatively current patient guidelines and fact sheets on heroin dependence. Originally founded in 1887, the NIH is one of the world's foremost medical research centers and the federal focal point for medical research in the United States. At any given time, the NIH supports some 35,000 research grants at universities, medical schools, and other research and training institutions, both nationally and internationally. The rosters of those who have conducted research or who have received NIH support over the years include the world's most illustrious scientists and physicians. Among them are 97 scientists who have won the Nobel Prize for achievement in medicine.

5

Adapted from the NIH: http://www.nih.gov/about/NIHoverview.html.

10 Heroin Dependence

There is no guarantee that any one Institute will have a guideline on a specific disease, though the National Institutes of Health collectively publish over 600 guidelines for both common and rare diseases. The best way to access NIH guidelines is via the Internet. Although the NIH is organized into many different Institutes and Offices, the following is a list of key Web sites where you are most likely to find NIH clinical guidelines and publications dealing with heroin dependence and associated conditions: ·

Office of the Director (OD); guidelines consolidated across agencies available at http://www.nih.gov/health/consumer/conkey.htm

·

National Library of Medicine (NLM); extensive encyclopedia (A.D.A.M., Inc.) with guidelines available at http://www.nlm.nih.gov/medlineplus/healthtopics.html

·

National Institute on Drug Abuse (NIDA); guidelines on abused drugs at http://www.nida.nih.gov/DrugAbuse.html

Among these, the National Institute on Drug Abuse is particularly noteworthy.6 NIDA was established in 1974, and in October 1992 it became part of the National Institutes of Health, Department of Health and Human Services. The Institute is organized into divisions and offices, each of which plays an important role in programs of drug abuse research. NIDA's mission is to lead the Nation in bringing the power of science to bear on drug abuse and addiction. This charge has two critical components. The first is the strategic support and conduct of research across a broad range of disciplines. The second is to ensure the rapid and effective dissemination and use of the results of that research to significantly improve drug abuse and addiction prevention, treatment, and policy. NIDA supports over 85 percent of the world's research on the health aspects of drug abuse and addiction. NIDA supported science addresses the most fundamental and essential questions about drug abuse, ranging from the molecule to managed care, and from DNA to community outreach research. NIDA is not only seizing upon unprecedented opportunities and technologies to further understanding of how drugs of abuse affect the brain and behavior, but also working to ensure the rapid and effective transfer of scientific data to policy makers, drug abuse practitioners, other health care practitioners and the general public. The NIDA web page is an important part of this effort (http://www.nida.nih.gov/). Before citing NIDA's most

The section is reproduced or adapted from the NIDA: http://www.nida.nih.gov/NIDAWelcome.html#Mission. For the remainder of this book, “adapted” signifies attributed “reproduction” with formatting and other minimal editorial changes. 6

Guidelines 11

recent guideline on heroin dependence, the discussion below reproduces NIDA's general overview of drug abuse and addiction. Understanding Drug Abuse and Addiction7 Many people view drug abuse and addiction as strictly a social problem. Parents, teens, older adults, and other members of the community tend to characterize people who take drugs as morally weak or as having criminal tendencies. They believe that drug abusers and addicts should be able to stop taking drugs if they are willing to change their behavior. These myths have not only stereotyped those with drug-related problems, but also their families, their communities, and the health care professionals who work with them. Drug abuse and addiction comprise a public health problem that affects many people and has wide-ranging social consequences. It is NIDA's goal to help the public replace its myths and long-held mistaken beliefs about drug abuse and addiction with scientific evidence that addiction is a chronic, relapsing, and treatable disease. Addiction does begin with drug abuse when an individual makes a conscious choice to use drugs, but addiction is not just “a lot of drug use.” Recent scientific research provides overwhelming evidence that not only do drugs interfere with normal brain functioning creating powerful feelings of pleasure, but they also have long-term effects on brain metabolism and activity. At some point, changes occur in the brain that can turn drug abuse into addiction, a chronic, relapsing illness. Those addicted to drugs suffer from a compulsive drug craving and usage and cannot quit by themselves. Treatment is necessary to end this compulsive behavior. A variety of approaches are used in treatment programs to help patients deal with these cravings and possibly avoid drug relapse. NIDA research shows that addiction is clearly treatable. Through treatment that is tailored to individual needs, patients can learn to control their condition and live relatively normal lives. Treatment can have a profound effect not only on drug abusers, but on society as a whole by significantly improving social and psychological functioning, decreasing related criminality and violence, and reducing the spread of AIDS. It can also dramatically reduce the costs to society of drug abuse. 7

Adapted from http://165.112.78.61/Infofax/understand.html.


Understanding drug abuse also helps in understanding how to prevent use in the first place. Results from NIDA-funded prevention research have shown that comprehensive prevention programs that involve the family, schools, communities, and the media are effective in reducing drug abuse. It is necessary to keep sending the message that it is better to not start at all than to enter rehabilitation if addiction occurs. A tremendous opportunity exists to effectively change the ways in which the public understands drug abuse and addiction because of the wealth of scientific data NIDA has amassed. Overcoming misconceptions and replacing ideology with scientific knowledge is the best hope for bridging the “great disconnect” - the gap between the public perception of drug abuse and addiction and the scientific facts. The National Institutes of Health has recently published the following guideline for heroin dependence:

What Is Heroin?8 Heroin is an illegal, highly addictive drug. It is both the most abused and the most rapidly acting of the opiates. Heroin is processed from morphine, a naturally occurring substance extracted from the seed pod of certain varieties of poppy plants. It is typically sold as a white or brownish powder or as the black sticky substance known on the streets as “black tar heroin.” Although purer heroin is becoming more common, most street heroin is “cut” with other drugs or with substances such as sugar, starch, powdered milk, or quinine. Street heroin can also be cut with strychnine or other poisons. Because heroin abusers do not know the actual strength of the drug or its true contents, they are at risk of overdose or death. Heroin also poses special problems because of the transmission of HIV and other diseases that can occur from sharing needles or other injection equipment.

What Is the Scope of Heroin Use in the United States? According to the 1998 National Household Survey on Drug Abuse, which may actually underestimate illicit opiate (heroin) use, an estimated 2.4 million people had used heroin at some time in their lives, and nearly Adapted from The National Institute on Drug Abuse: http://165.112.78.61/ResearchReports/Heroin/Heroin.html.

8

Guidelines 13

130,000 of them reported using it within the month preceding the survey. The survey report estimates that there were 81,000 new heroin users in 1997. A large proportion of these recent new users were smoking, snorting, or sniffing heroin, and most (87 percent) were under age 26. In 1992, only 61 percent were younger than 26. The 1998 Drug Abuse Warning Network (DAWN), which collects data on drug-related hospital emergency department (ED) episodes from 21 metropolitan areas, estimates that 14 percent of all drug-related ED episodes involved heroin. Even more alarming is the fact that between 1991 and 1996, heroin-related ED episodes more than doubled (from 35,898 to 73,846). Among youths aged 12 to 17, heroin-related episodes nearly quadrupled. NIDA's Community Epidemiology Work Group (CEWG), which provides information about the nature and patterns of drug use in 21 cities, reported in its December 1999 publication that heroin was mentioned most often as the primary drug of abuse in drug abuse treatment admissions in Baltimore, Boston, Los Angeles, Newark, New York, and San Francisco.

How Is Heroin Used? Heroin is usually injected, sniffed/snorted, or smoked. Typically, a heroin abuser may inject up to four times a day. Intravenous injection provides the greatest intensity and most rapid onset of euphoria (7 to 8 seconds), while intramuscular injection produces a relatively slow onset of euphoria (5 to 8 minutes). When heroin is sniffed or smoked, peak effects are usually felt within 10 to 15 minutes. Although smoking and sniffing heroin do not produce a “rush” as quickly or as intensely as intravenous injection, NIDA researchers have confirmed that all three forms of heroin administration are addictive.


Route of Administration Among Heroin Treatment Admissions in Selected Areas

Source: Community Epidemiology Work Group, NIDA, December 1999 Injection continues to be the predominant method of heroin use among addicted users seeking treatment; however, researchers have observed a shift in heroin use patterns, from injection to sniffing and smoking. In fact, sniffing/snorting heroin is now the most widely reported means of taking heroin among users admitted for drug treatment in Newark, Chicago, and New York. With the shift in heroin abuse patterns comes an even more diverse group of users. Older users (over 30) continue to be one of the largest user groups in most national data. However, the increase continues in new, young users across the country who are being lured by inexpensive, high-purity heroin that can be sniffed or smoked instead of injected. Heroin has also been appearing in more affluent communities.

What Are the Immediate (Short-Term) Effects of Heroin Use? Short-term effects: ·

“Rush”

·

Depressed respiration

·

Clouded mental functioning

·

Nausea and vomiting

·

Suppression of pain

·

Spontaneous abortion

Guidelines 15

Soon after injection (or inhalation), heroin crosses the blood-brain barrier. In the brain, heroin is converted to morphine and binds rapidly to opioid receptors. Abusers typically report feeling a surge of pleasurable sensation, a “rush.” The intensity of the rush is a function of how much drug is taken and how rapidly the drug enters the brain and binds to the natural opioid receptors. Heroin is particularly addictive because it enters the brain so rapidly. With heroin, the rush is usually accompanied by a warm flushing of the skin, dry mouth, and a heavy feeling in the extremities, which may be accompanied by nausea, vomiting, and severe itching. After the initial effects, abusers usually will be drowsy for several hours. Mental function is clouded by heroin's effect on the central nervous system. Cardiac function slows. Breathing is also severely slowed, sometimes to the point of death. Heroin overdose is a particular risk on the street, where the amount and purity of the drug cannot be accurately known.

What Are the Long-Term Effects of Heroin Use? Long-term effects: ·

Addiction

·

Infectious diseases, for example, HIV/AIDS and hepatitis B and C

·

Collapsed veins


·

Bacterial infections

·

Abscesses

·

Infection of heart lining and valves

·

Arthritis and other rheumatologic problems

One of the most detrimental long-term effects of heroin is addiction itself. Addiction is a chronic, relapsing disease, characterized by compulsive drug seeking and use, and by neurochemical and molecular changes in the brain. Heroin also produces profound degrees of tolerance and physical dependence, which are also powerful motivating factors for compulsive use and abuse. As with abusers of any addictive drug, heroin abusers gradually spend more and more time and energy obtaining and using the drug. Once they are addicted, the heroin abusers' primary purpose in life becomes seeking and using drugs. The drugs literally change their brains. Physical dependence develops with higher doses of the drug. With physical dependence, the body adapts to the presence of the drug and withdrawal symptoms occur if use is reduced abruptly. Withdrawal may occur within a few hours after the last time the drug is taken. Symptoms of withdrawal include restlessness, muscle and bone pain, insomnia, diarrhea, vomiting, cold flashes with goose bumps (“cold turkey”), and leg movements. Major withdrawal symptoms peak between 24 and 48 hours after the last dose of heroin and subside after about a week. However, some people have shown persistent withdrawal signs for many months. Heroin withdrawal is never fatal to otherwise healthy adults, but it can cause death to the fetus of a pregnant addict. At some point during continuous heroin use, a person can become addicted to the drug. Sometimes addicted individuals will endure many of the withdrawal symptoms to reduce their tolerance for the drug so that they can again experience the rush. Physical dependence and the emergence of withdrawal symptoms were once believed to be the key features of heroin addiction. We now know this may not be the case entirely, since craving and relapse can occur weeks and months after withdrawal symptoms are long gone. We also know that patients with chronic pain who need opiates to function (sometimes over extended periods) have few if any problems leaving opiates after their pain is resolved by other means. This may be because the patient in pain is simply seeking relief of pain and not the rush sought by the addict.

Guidelines 17

What Are the Medical Complications of Chronic Heroin Use? Medical consequences of chronic heroin abuse include scarred and/or collapsed veins, bacterial infections of the blood vessels and heart valves, abscesses (boils) and other soft-tissue infections, and liver or kidney disease. Lung complications (including various types of pneumonia and tuberculosis) may result from the poor health condition of the abuser as well as from heroin's depressing effects on respiration. Many of the additives in street heroin may include substances that do not readily dissolve and result in clogging the blood vessels that lead to the lungs, liver, kidneys, or brain. This can cause infection or even death of small patches of cells in vital organs. Immune reactions to these or other contaminants can cause arthritis or other rheumatologic problems. Of course, sharing of injection equipment or fluids can lead to some of the most severe consequences of heroin abuse-infections with hepatitis B and C, HIV, and a host of other blood-borne viruses, which drug abusers can then pass on to their sexual partners and children.

How Does Heroin Abuse Affect Pregnant Women? Heroin abuse can cause serious complications during pregnancy, including miscarriage and premature delivery. Children born to addicted mothers are at greater risk of SIDS (sudden infant death syndrome), as well. Pregnant women should not be detoxified from opiates because of the increased risk of spontaneous abortion or premature delivery; rather, treatment with methadone is strongly advised. Although infants born to mothers taking prescribed methadone may show signs of physical dependence, they can be treated easily and safely in the nursery. Research has demonstrated also that the effects of in utero exposure to methadone are relatively benign.

Why Are Heroin Users at Special Risk for Contracting HIV/AIDS and Hepatitis B and C? Heroin addicts are at risk for contracting HIV, hepatitis C, and other infectious diseases. Drug abusers may become infected with HIV, hepatitis C, and other blood-borne pathogens through sharing and reuse of syringes and injection paraphernalia that have been used by infected individuals. They may also become infected with HIV and, although less often, to hepatitis C through unprotected sexual contact with an infected person.


Injection drug use has been a factor in an estimated one-third of all HIV and more than half of all hepatitis C cases in the Nation. NIDA-funded research has found that drug abusers can change the behaviors that put them at risk for contracting HIV, through drug abuse treatment, prevention, and community-based outreach programs. They can eliminate drug use, drug-related risk behaviors such as needle sharing, unsafe sexual practices, and, in turn, the risk of exposure to HIV/AIDS and other infectious diseases. Drug abuse prevention and treatment are highly effective in preventing the spread of HIV.

What Are the Treatments for Heroin Addiction? A variety of effective treatments are available for heroin addiction. Treatment tends to be more effective when heroin abuse is identified early. The treatments that follow vary depending on the individual, but methadone, a synthetic opiate that blocks the effects of heroin and eliminates withdrawal symptoms, has a proven record of success for people addicted to heroin. Other pharmaceutical approaches, like LAAM (levo-alpha-acetylmethadol) and buprenorphine, and many behavioral therapies also are used for treating heroin addiction.

Detoxification The primary objective of detoxification is to relieve withdrawal symptoms while patients adjust to a drug-free state. Not in itself a treatment for addiction, detoxification is a useful step only when it leads into long-term treatment that is either drug-free (residential or outpatient) or uses medications as part of the treatment. The best documented drug-free treatments are the therapeutic community residential programs lasting at least 3 to 6 months.

Methadone Programs Methadone treatment has been used effectively and safely to treat opioid addiction for more than 30 years. Properly prescribed methadone is not intoxicating or sedating, and its effects do not interfere with ordinary activities such as driving a car. The medication is taken orally and it suppresses narcotic withdrawal for 24 to 36 hours. Patients are able to perceive pain and have emotional reactions. Most important, methadone

Guidelines 19

relieves the craving associated with heroin addiction; craving is a major reason for relapse. Among methadone patients, it has been found that normal street doses of heroin are ineffective at producing euphoria, thus making the use of heroin more easily extinguishable. Methadone's effects last for about 24 hours - four to six times as long as those of heroin - so people in treatment need to take it only once a day. Also, methadone is medically safe even when used continuously for 10 years or more. Combined with behavioral therapies or counseling and other supportive services, methadone enables patients to stop using heroin (and other opiates) and return to more stable and productive lives. Methadone dosages must be carefully monitored in patients who are receiving antiviral therapy for HIV infection, to avoid potential medication interactions.

LAAM and Other Medications LAAM, like methadone, is a synthetic opiate that can be used to treat heroin addiction. LAAM can block the effects of heroin for up to 72 hours with minimal side effects when taken orally. In 1993 the Food and Drug Administration approved the use of LAAM for treating patients addicted to heroin. Its long duration of action permits dosing just three times per week, thereby eliminating the need for daily dosing and take-home doses for weekends. LAAM will be increasingly available in clinics that already dispense methadone. Naloxone and naltrexone are medications that also block the effects of morphine, heroin, and other opiates. As antagonists, they are especially useful as antidotes. Naltrexone has long-lasting effects, ranging from 1 to 3 days, depending on the dose. Naltrexone blocks the pleasurable effects of heroin and is useful in treating some highly motivated individuals. Naltrexone has also been found to be successful in preventing relapse by former opiate addicts released from prison on probation. Another medication to treat heroin addiction, buprenorphine, may already be available by the time this Research Report appears. Buprenorphine is a particularly attractive treatment because, compared to other medications, such as methadone, it causes weaker opiate effects and is less likely to cause overdose problems. Buprenorphine also produces a lower level of physical dependence, so patients who discontinue the medication generally have fewer withdrawal symptoms than do those who stop taking methadone. Because of these advantages, buprenorphine may be appropriate for use in a wider variety of treatment settings than the currently available medications.


Several other medications with potential for treating heroin overdose or addiction are currently under investigation by NIDA.

Behavioral Therapies Although behavioral and pharmacologic treatments can be extremely useful when employed alone, science has taught us that integrating both types of treatments will ultimately be the most effective approach. There are many effective behavioral treatments available for heroin addiction. These can include residential and outpatient approaches. An important task is to match the best treatment approach to meet the particular needs of the patient. Moreover, several new behavioral therapies, such as contingency management therapy and cognitive-behavioral interventions, show particular promise as treatments for heroin addiction. Contingency management therapy uses a voucher-based system, where patients earn points based on negative drug tests, which they can exchange for items that encourage healthy living. Cognitive-behavioral interventions are designed to help modify the patient's thinking, expectancies, and behaviors and to increase skills in coping with various life stressors. Both behavioral and pharmacological treatments help to restore a degree of normalcy to brain function and behavior, with increased employment rates and lower risk of HIV and other diseases and criminal behavior.

What Are the Opioid Analogs and Their Dangers? Drug analogs are chemical compounds that are similar to other drugs in their effects but differ slightly in their chemical structure. Some analogs are produced by pharmaceutical companies for legitimate medical reasons. Other analogs, sometimes referred to as “designer” drugs, can be produced in illegal laboratories and are often more dangerous and potent than the original drug. Two of the most commonly known opioid analogs are fentanyl and meperidine (marketed under the brand name Demerol, for example). Fentanyl was introduced in 1968 by a Belgian pharmaceutical company as a synthetic narcotic to be used as an analgesic in surgical procedures because of its minimal effects on the heart. Fentanyl is particularly dangerous because it is 50 times more potent than heroin and can rapidly stop respiration. This is not a problem during surgical procedures because machines are used to help patients breathe. On the street, however, users

Guidelines 21

have been found dead with the needle used to inject the drug still in their arms.

Where Can I Get Further Scientific Information about Heroin Abuse and Addiction? To learn more about heroin and other drugs of abuse, contact the National Clearinghouse for Alcohol and Drug Information (NCADI) at 1-800-7296686. Information specialists are available to assist you in locating needed information and resources. Information can be accessed also through the NIDA World Wide Web site (http://www.drugabuse.gov) or the NCADI Web site (http://www.health.org). In particular, the following web site provides NIDA's research report on heroin abuse: http://165.112.78.61/ResearchReports/heroin/heroin.html.

Heroin INFOFAX9 In addition to the guideline above, NIDA also publishes shorter guidelines in the form of INFOFAXs. The INFOFAX below is one recently dedicated to heroin: Heroin is a highly addictive drug, and its use is a serious problem in America. Recent studies suggest a shift from injecting heroin to snorting or smoking because of increased purity and the misconception that these forms of use will not lead to addiction. Heroin is processed from morphine, a naturally occurring substance extracted from the seedpod of the Asian poppy plant. Heroin usually appears as a white or brown powder. Street names for heroin include “smack,” “H,” “skag,” and “junk.” Other names may refer to types of heroin produced in a specific geographical area, such as “Mexican black tar.”

Health Hazards Heroin abuse is associated with serious health conditions, including fatal overdose, spontaneous abortion, collapsed veins, and infectious diseases, including HIV/AIDS and hepatitis.

9

Adapted from http://165.112.78.61/Infofax/heroin.html.


The short-term effects of heroin abuse appear soon after a single dose and disappear in a few hours. After an injection of heroin, the user reports feeling a surge of euphoria (“rush”) accompanied by a warm flushing of the skin, a dry mouth, and heavy extremities. Following this initial euphoria, the user goes “on the nod,” an alternately wakeful and drowsy state. Mental functioning becomes clouded due to the depression of the central nervous system. Long-term effects of heroin appear after repeated use for some period of time. Chronic users may develop collapsed veins, infection of the heart lining and valves, abscesses, cellulitis, and liver disease. Pulmonary complications, including various types of pneumonia, may result from the poor health condition of the abuser, as well as from heroin's depressing effects on respiration. In addition to the effects of the drug itself, street heroin may have additives that do not readily dissolve and result in clogging the blood vessels that lead to the lungs, liver, kidneys, or brain. This can cause infection or even death of small patches of cells in vital organs. Reports from SAMHSA's 1995 Drug Abuse Warning Network (DAWN), which collects data on drug-related hospital emergency room episodes and drug-related deaths from 21 metropolitan areas, rank heroin second as the most frequently mentioned drug in overall drug-related deaths. From 1990 through 1995, the number of heroin-related episodes doubled. Between 1994 and 1995, there was a 19 percent increase in heroin-related emergency department episodes.

Tolerance, Addiction, and Withdrawal With regular heroin use, tolerance develops. This means the abuser must use more heroin to achieve the same intensity or effect. As higher doses are used over time, physical dependence and addiction develop. With physical dependence, the body has adapted to the presence of the drug and withdrawal symptoms may occur if use is reduced or stopped. Withdrawal, which in regular abusers may occur as early as a few hours after the last administration, produces drug craving, restlessness, muscle and bone pain, insomnia, diarrhea and vomiting, cold flashes with goose bumps (“cold turkey”), kicking movements (“kicking the habit”), and other symptoms. Major withdrawal symptoms peak between 48 and 72 hours after the last dose and subside after about a week. Sudden withdrawal by heavily dependent users who are in poor health is occasionally fatal, although heroin

Guidelines 23

withdrawal is considered much less dangerous than alcohol or barbiturate withdrawal.

Treatment There is a broad range of treatment options for heroin addiction, including medications as well as behavioral therapies. Science has taught us that when medication treatment is integrated with other supportive services, patients are often able to stop heroin (or other opiate) use and return to more stable and productive lives. In November 1997, the National Institutes of Health (NIH) convened a Consensus Panel on Effective Medical Treatment of Heroin Addiction. The panel of national experts concluded that opiate drug addictions are diseases of the brain and medical disorders that indeed can be treated effectively. The panel strongly recommended (1) broader access to methadone maintenance treatment programs for people who are addicted to heroin or other opiate drugs; and (2) the Federal and State regulations and other barriers impeding this access be eliminated. This panel also stressed the importance of providing substance abuse counseling, psychosocial therapies, and other supportive services to enhance retention and successful outcomes in methadone maintenance treatment programs. The panel's full consensus statement is available by calling 1-888-NIH-CONSENSUS (1-888-644-2667) or by visiting the NIH Consensus Development Program Web site at http://consensus.nih.gov. Methadone, a synthetic opiate medication that blocks the effects of heroin for about 24 hours, has a proven record of success when prescribed at a high enough dosage level for people addicted to heroin. LAAM, also a synthetic opiate medication for treating heroin addiction, can block the effects of heroin for up to 72 hours. Other approved medications are naloxone, which is used to treat cases of overdose, and naltrexone, both of which block the effects of morphine, heroin, and other opiates. Several other medications for use in heroin treatment programs are also under study. There are many effective behavioral treatments available for heroin addiction. These can include residential and outpatient approaches. Several new behavioral therapies are showing particular promise for heroin addiction. Contingency management therapy uses a voucher-based system, where patients earn “points” based on negative drug tests, which they can exchange for items that encourage healthful living. Cognitive-behavioral interventions are designed to help modify the patient's thinking,


expectancies, and behaviors and to increase skills in coping with various life stressors.

Extent of Use The Monitoring the Future Study (MTF) The MTF survey is conducted by the University of Michigan's Institute for Social Research and is funded by National Institute on Drug Abuse, National Institutes of Health; it has tracked 12th graders' illicit drug use and related attitudes since 1975. In 1991, 8th and 10th graders were added to the study. For the 1998 study, 49,866 students were surveyed from a representative sample of 422 public and private schools nationwide. Copies of the latest survey are available from the National Clearinghouse for Alcohol and Drug Information at 1-800-729-6686. According to the 1999 MTF, rates of heroin use remained relatively stable and low since the late 1970s. After 1991, however, use began to rise among 10th- and 12th-graders, and after 1993, among 8th-graders. In 1999, prevalence of heroin use was comparable for all three grade levels. Although past year prevalence rates for heroin use remained relatively low in 1999, these rates are about two to three times higher than those reported in 1991. Heroin Use by Students, 1999: Monitoring the Future Study 8th-Graders

10th-Graders

12th-Graders

Ever Used*

2.3%

2.3%

2.0%

Used in Past Year*

1.4

1.4

1.1

Used in Past Month*

0.6

0.7

0.5

*State Resources and Services Related to Alcohol and Other Drug Problems for Fiscal Year 1995: An Analysis of State Alcohol and Drug Abuse Profile Data, written by the National Association of State Alcohol and Drug Abuse Directors (NASADAD), July 1997, is available from NASADAD at 202-293-0090. Community Epidemiology Work Group (CEWG) CEWG is a NIDA-sponsored network of researchers from 20 major U.S. metropolitan areas and selected foreign countries who meet semiannually to

Guidelines 25

discuss the current epidemiology of drug abuse. CEWG's most recent report is Epidemiologic Trends in Drug Abuse, Volume I, June 2000. In June 2000, CEWG members reported that heroin indicators showed mixed trends. Mortality figures were mixed, with deaths increasing notably in Austin, Detroit, Minneapolis/St. Paul, and Phoenix, and declining in Miami, Philadelphia, St. Louis, San Diego, and Seattle. Emergency room admissions were also mixed, with 10 cities showing decreases (significant in San Francisco and Washington, D.C.), and 10 showing increases (particularly Baltimore and Miami). Heroin continues to account for a substantial proportion of treatment admissions in some CEWG areas (e.g., 47.8 percent in Baltimore, 43 percent in New York City, and 32 percent in Detroit). Heroin injection characterizes a large proportion of primary heroin treatment admissions (e.g., 90 percent in Texas). During the second quarter of 1999, the highest purity levels were found in Philadelphia (71 percent); New York (63.6 percent); Boston (61.4 percent); Newark (60.7 percent); Atlanta (57.8 percent); and San Diego (57.6 percent). Purity levels in other CEWG areas ranged from 11.8 percent in Dallas to 46.7 percent in Detroit. Injecting is on an upward trend among younger users in Baltimore, Boston, Minneapolis/St. Paul, Newark, New York City, and Seattle. In Boston, Chicago, Denver, Miami, and Washington, D.C., snorting seems to be increasing and is often the starting route for new users.

The National Household Survey on Drug Abuse (NHSDA) NHSDA is an annual survey conducted by the Substance Abuse and Mental Health Services administration. Copies of the latest survey are available from the National Clearinghouse for Alcohol and Drug Information at 1-800-7296686. The 1999 NHSDA study reports the use of illicit drugs by those people age 12 and older. The lifetime prevalence (at least one use in a persons lifetime) for heroin for those people age 12 and older was 1.4 percent. By age category, 0.4 percent were in the 12-17 range; 1.8 percent were 18-25; and 1.4 percent were users age 26 and older. “Lifetime” refers to use at least once during a respondent's lifetime. “Past year” refers to an individual's drug use at least once during the year preceding their response to the survey. “Past month” refers to an individual's drug use at least once during the month preceding their response to the survey.

NIH Consensus Statement on Opiate Addiction Treatment NIH Consensus Development Conferences are convened to evaluate available scientific information and resolve safety and efficacy issues related


to biomedical technology. The resultant NIH Consensus Statements are intended to advance understanding of the technology or issue in question and to be useful to health professionals and the public.10 Each NIH consensus statement is the product of an independent, non-Federal panel of experts and is based on the panel's assessment of medical knowledge available at the time the statement was written. Therefore, a consensus statement provides a “snapshot in time” of the state of knowledge of the conference topic. The NIH makes the following caveat: “When reading or downloading NIH consensus statements, keep in mind that new knowledge is inevitably accumulating through medical research. Nevertheless, each NIH consensus statement is retained on this website in its original form as a record of the NIH Consensus Development Program.”11 The following concensus statement was posted on the NIH site and not indicated as “out of date” in March 2002. It was originally published, however, in November 1997.12

Objective To provide health care providers, patients, and the general public with a responsible assessment of the effective approaches for treating opiate dependence.

Participants A non-Federal, nonadvocate, 12-member panel representing the fields of psychology, psychiatry, behavioral medicine, family medicine, drug abuse, epidemiology, and the public. In addition, 25 experts from these same fields presented data to the panel and a conference audience of 600.

Evidence The literature was searched through Medline and an extensive bibliography of references was provided to the panel and the conference audience. Experts prepared abstracts with relevant citations from the literature. Scientific evidence was given precedence over clinical anecdotal experience. This paragraph is adapted from the NIH: http://odp.od.nih.gov/consensus/cons/cons.htm. Adapted from the NIH: http://odp.od.nih.gov/consensus/cons/consdate.htm. 12 Effective Medical Treatment of Opiate Addiction. NIH Consens Statement Online 1997 Nov 17-19; [cited 2002 February 20];15(6):1-38. http://consensus.nih.gov/cons/108/108_statement.htm. 10 11

Guidelines 27

Consensus Process The panel, answering predefined questions, developed their conclusions based on the scientific evidence presented in open forum and the scientific literature. The panel composed a draft statement that was read in its entirety and circulated to the experts and the audience for comment. Thereafter, the panel resolved conflicting recommendations and released a revised statement at the end of the conference. The panel finalized the revisions within a few weeks after the conference. The draft statement was made available on the World Wide Web immediately following its release at the conference and was updated with the panel's final revisions.

Conclusions Opiate dependence is a brain-related medical disorder that can be effectively treated with significant benefits for the patient and society, and society must make a commitment to offer effective treatment for opiate dependence to all who need it. All opiate-dependent persons under legal supervision should have access to methadone maintenance therapy, and the U.S. Office of National Drug Control Policy and the U.S. Department of Justice should take the necessary steps to implement this recommendation. There is a need for improved training for physicians and other health care professionals and in medical schools in the diagnosis and treatment of opiate dependence. The unnecessary regulations of methadone maintenance therapy and other longacting opiate agonist treatment programs should be reduced, and coverage for these programs should be a required benefit in public and private insurance programs.

What Are Treatments for Opiate Addiction? In the United States, before 1914, it was relatively common for private physicians to treat opiate-dependent patients in their practices by prescribing narcotic medications. While the passage of the Harrison Act did not prohibit the prescribing of a narcotic by a physician to treat an addicted patient, this practice was viewed as problematic by Treasury officials charged with enforcing the law. Physicians who continued to prescribe were indicted and prosecuted. Because of withdrawal of treatment by physicians, various local governments and communities established formal morphine clinics for treating opiate addiction. These clinics were eventually closed when the AMA, in 1920, stated that there was unanimity that prescribing opiates to addicts for self-administration (ambulatory treatment) was not an


acceptable medical practice. For the next 50 years, opiate addiction was basically managed in this country by the criminal justice system and the two Federal Public Health Hospitals in Lexington, Kentucky, and Fort Worth, Texas. The relapse rate for opiate use from this approach was close to 100 percent. During the 1960s opiate use reached epidemic proportions in the United States, spawning significant increases in crime and in deaths from opiate overdose. The increasing number of younger people entering an addiction lifestyle indicated that a major societal problem was emerging. This stimulated a search for innovative and more effective methods to treat the growing number of individuals dependent upon opiates. This search resulted in the emergence of drug-free therapeutic communities and the use of the opiate agonist, methadone, to maintain those with opiate dependence. Furthermore, a multimodality treatment strategy was designed to meet the needs of the individual addict patient. These three approaches remain the main treatment strategies being used to treat opiate dependence in the United States today. Opiate dependence has long been associated with increased criminal activity. For example, in 1993 more than one-quarter of the inmates in State and Federal prisons were incarcerated for drug offenses (234,600), and prisoners serving drug sentences were the largest single group (60 percent) in Federal prisons. In the past 10 years, there has been a dramatic increase in the prevalence of human immunodeficiency virus (HIV), hepatitis B and C viruses, and tuberculosis among intravenous opiate users. From 1991 to 1995, in major metropolitan areas, the annual number of opiate-related emergency room visits increased from 36,000 to 76,000, and the annual number of opiaterelated deaths increased from 2,300 to 4,000. This associated morbidity and mortality further underscore the human, economic, and societal costs of opiate dependence. During the last two decades, evidence has accumulated on the neurobiology of opiate dependence. Whatever conditions may lead to opiate exposure, opiate dependence is a brain-related disorder with the requisite characteristics of a medical illness. Thus, opiate dependence as a medical illness will have varying causative mechanisms. There is a need to identify discrete subgroups of opiate-dependent people and the most relevant and effective treatments for each subgroup. The safety and efficacy of narcotic agonist (methadone) maintenance treatment has been unequivocally established. Although there are other medications (e.g., levo-alpha acetylmethadol [LAAM] and naltrexone, an opiate antagonist, etc.) that are safe and effective in the treatment of opiate addicts, the focus of this

Guidelines 29

consensus development conference was primarily on methadone maintenance treatment (MMT). MMT is effective in reducing illicit opiate drug use, in reducing crime, in enhancing social productivity, and in reducing the spread of viral diseases such as AIDS and hepatitis. Approximately 115,000 of the estimated 600,000 opiate-dependent persons in the United States are in MMT. Science has not yet overcome the stigma of addiction and the negative public perception about MMT. Some leaders in the Federal Government, public health officials, members of the medical community, and the public-at-large frequently conceive of opiate dependence as a self-inflicted disease of the will or as a moral flaw. They also regard MMT as an ineffective narcotic substitution and believe that a drugfree state is the only valid treatment goal. Other obstacles to MMT include Federal and State government regulations that restrict the number of treatment providers and patient access. Some of these Federal and State regulations are driven by disproportionate concerns about methadone diversion, concern about premature (e.g., in 12-year-olds) initiation of maintenance treatment, and concern about provision of methadone without any other psychosocial services. Although a drug-free state represents an optimal treatment goal, research has demonstrated that this goal cannot be achieved or sustained by the majority of opiate-dependent people. However, other laudable treatment goals including decreased drug use, reduced criminal activity, and gainful employment can be achieved by most MMT patients. To address the most important issues surrounding effective medical treatment of opiate dependence, the NIH organized this 2 1/2-day conference to present data on opiate agonist treatment for opiate dependence. The conference brought together national and international experts in the fields of the basic and clinical medical sciences, epidemiology, natural history, prevention and treatment of opiate dependence, and broad representation from the public. After 1 1/2 days of presentations and audience discussion, an independent, non-Federal consensus panel chaired by Lewis L. Judd, M.D., Mary Gilman Marston Professor, Chair of the Department of Psychiatry, University of California, San Diego School of Medicine, weighed the scientific evidence and wrote a draft statement that was presented to the audience on the third day. The consensus statement addressed the following key questions: ·

What is the scientific evidence to support a conceptualization of opiate addiction as a medical disorder including natural history, genetics and risk factors, and pathophysiology, and how is diagnosis established?


·

What are the consequences of untreated opiate addiction to individuals, families, and society?

·

What is the efficacy of current treatment modalities in the management of opiate addiction including detoxification alone, nonpharmacological/psychosocial treatment, treatment with opiate antagonists, and treatment with opiate agonists (short term and long term)? And, what is the scientific evidence for the most effective use of opiate agonists in the treatment of opiate addiction?

·

What are the important barriers to effective use of opiate agonists in the treatment of opiate addiction in the United States, including perceptions and the adverse consequences of opiate agonist use and legal, regulatory, financial, and programmatic barriers?

·

What are the future research areas and recommendations for improving opiate agonist treatment and improving access?

Is Opiate Dependence a Medical Disorder? The Natural History of Opiate Dependence Individuals addicted to opiates often become dependent on these drugs by their early twenties and remain intermittently dependent for decades. Biological, psychological, sociological, and economic factors determine when an individual will start taking opiates. However, it is clear that when use begins, it often escalates to abuse (repeated use with adverse consequences) and then to dependence (opioid tolerance, withdrawal symptoms, compulsive drug-taking). Once dependence is established, there are usually repeated cycles of cessation and relapse extending over decades. This “addiction career” is often accompanied by periods of imprisonment. Treatment can alter the natural history of opiate dependence, most commonly by prolonging periods of abstinence from illicit opiate abuse. Of the various treatments available, MMT, combined with attention to medical, psychiatric, and socioeconomic issues, as well as drug counseling, has the highest probability of being effective. Addiction-related deaths, including accidental overdose, drug-related accidents, and many illnesses directly attributable to chronic drug dependence explain one-fourth to one-third of the mortality in an opiateaddicted population. As a population of opiate addicts ages, there is a decrease in the percentage who are still addicted.

Guidelines 31

There is clearly a natural history of opiate dependence, but causative factors are poorly understood. It is especially unclear for a given individual whether repeated use begins as a medical disorder (e.g., a genetic predisposition) or whether socioeconomic and psychological factors lead an individual to try and then later to compulsively use opiates. However, there is no question that once the individual is dependent on opiates, such dependence constitutes a medical disorder. Molecular Neurobiology and Pathogenesis of Opiate Dependence: Genetic and Other Risk Factors for Opiate Dependence Twin, family, and adoption studies show that vulnerability to drug abuse may be a partially inherited condition with strong influences from environmental factors. Cross-fostering adoption studies have demonstrated that both inherited and environmental factors operate in the etiology of drug abuse. These cross-fostering adoption studies identified two distinct genetic pathways to drug abuse/dependence. The first is a direct effect of substance abuse in a biologic parent. The second pathway is an indirect effect from antisocial personality disorder in a biologic parent, leading to both antisocial personality disorder and drug abuse/dependence in the adoptee. Family studies report significantly increased relative risk for substance abuse (6.7fold increased risk), alcoholism (3.5), antisocial personality (7.6), and unipolar depression (5.1) among the first-degree relatives of opiatedependent patients compared with relatives of controls. The siblings of opiate-dependent patients have very high susceptibility to abuse and dependence after initial use of illicit opioids. Twin studies indicate substantial heritability for substance abuse and dependence, with half the risk attributable to additive genetic factors.

Neurobiological Substrates of Opiate Dependence Dopaminergic pathways from the ventral tegmentum (VT) to the nucleus accumbens (NA) and medial frontal cortex (MFC) are activated during rewarding behaviors. Opiates exert their rewarding properties by binding to the “mu” opioid receptor (OPRM) at several distinct anatomical locations in the brain, including the VT, NA, MFC, and possibly the locus coeruleus (LC). Opiate agonist administration causes inhibition of the LC. Chronic administration of opioid agonists causes adaptation to the LC inhibition. Rapid discontinuation of opioid agonists (or administration of antagonists) results in excessive LC neuronal excitation and the appearance of withdrawal symptoms. Abnormal LC excitation is thought to underlie many


of the physical symptoms of withdrawal, and this hypothesis is consistent with the ability of clonidine, an alpha-2 noradrenergic agonist, to ameliorate opiate withdrawal. Regional Cerebral Glucose Metabolism in Opiate Abusers Two independent human studies (using positron emission tomography) suggest that opiates reduce cerebral glucose metabolism in a global manner, with no regions showing increased glucose utilization. A third study demonstrates decreased D2 receptor availability in opiate-dependent patients compared with controls. Opiate antagonist administration produced an intense withdrawal experience but did not change D2 receptor availability.

Diagnosis of Opioid Dependence Opioid dependence (addiction) is defined as a cluster of cognitive, behavioral, and physiological symptoms in which the individual continues use of opiates despite significant opiate-induced problems. Opioid dependence is characterized by repeated self-administration that usually results in opioid tolerance, withdrawal symptoms, and compulsive drugtaking. Dependence may occur with or without the physiological symptoms of tolerance and withdrawal. Usually, there is a long history of opioid selfadministration, typically via intravenous injection in the arms or legs, although recently, the intranasal route or smoking also is used. Often there is a history of drug-related crimes, drug overdoses, and family, psychological, and employment problems. There may be a history of physical problems including skin infections, hepatitis, HIV infection, or irritation of the nasal and pulmonary mucosa. Physical examination usually reveals puncture marks along veins in the arms and legs and “tracks” secondary to sclerosis of veins. If the patient has not taken opiates recently, he or she may also demonstrate symptoms of withdrawal, including anxiety, restlessness, runny nose, tearing, nausea, and vomiting. Tests for opioids in saliva and urine can help support a diagnosis of dependence. However, by itself, neither a positive nor a negative test can rule dependence in or out. Further evidence for opioid dependence can be obtained by a naloxone (Narcan) challenge test to induce withdrawal symptoms.

Guidelines 33

Evidence that Opioid Dependence Is a Medical Disorder For decades, opioid dependence was viewed as a problem of motivation, willpower, or strength of character. Through careful study of its natural history and through research at the genetic, molecular, neuronal, and epidemiological levels, it has been proven that opiate addiction is a medical disorder characterized by predictable signs and symptoms. Other arguments for classifying opioid dependence as a medical disorder include: ·

Despite varying cultural, ethnic, and socioeconomic backgrounds, there is clear consistency in the medical history, signs, and symptoms exhibited by individuals who are opiate-dependent.

·

There is a strong tendency to relapse after long periods of abstinence.

·

The opioid-dependent person's craving for opiates induces continual selfadministration even when there is an expressed and demonstrated strong motivation and powerful social consequences to stop.

·

Continuous exposure to opioids induces pathophysiologic changes in the brain.

Consequences of Untreated Opiate Dependence Of the estimated total opiate-dependent population of 600,000, only 115,000 are known to be in methadone maintenance treatment (MMT) programs. Research surveys indicate that the untreated population of opiate-addicted people is younger than those in treatment. They are typically in their late teens and early to mid-twenties, during their formative, early occupational, and reproductive years. The financial costs of untreated opiate dependence to the individual, the family, and society are estimated to be approximately $20 billion per year. The costs in human suffering are incalculable. What is currently known about the consequences of untreated opiate dependence to individuals, families, and society? Mortality Before the introduction of MMT, annual death rates reported in four American studies of opiate dependence varied from 13 per 1,000 to 44 per 1,000, with a median of 21 per 1,000. Although it cannot be causally attributed, it is interesting that after the introduction of MMT, the death rates of opiate-dependent persons in four American studies had a narrower range, from 11 per 1,000 to 15 per 1,000, and a median of 13 per 1,000. The most


striking evidence of the effectiveness of MMT on death rates is studies directly comparing these rates in opiate-dependent persons, on and off methadone. Every study showed that death rates were lower in opiatedependent persons maintained on methadone compared with those who are not. The median death rate for opiate-dependent persons in MMT was 30 percent of the death rate of those not in treatment. A clear consequence of not treating opiate dependence, therefore, is a death rate that is more than three times greater than that experienced by those engaged in MMT.

Illicit Drug Use Multiple studies conducted over several decades and in different countries demonstrate clearly that MMT results in a marked decrease in illicit opiate use. In addition, there is also a significant and consistent reduction in the use of other illicit drugs, including cocaine and marijuana, and in the abuse of alcohol, benzodiazepines, barbiturates, and amphetamines. Criminal Activity Opiate dependence in the United States is unequivocally associated with high rates of criminal behavior. More than 95 percent of opiate-dependent persons report committing crimes during an 11-year at-risk interval. These crimes range in severity from homicides to other crimes against people and property. Stealing in order to purchase drugs is the most common criminal offense. Over the past two decades, clear and convincing evidence has been collected from multiple studies that effective treatment of opiate dependence markedly reduces the rates of criminal activity. Therefore, it is clear that significant amounts of crime perpetrated by opiate-dependent persons are a direct consequence of untreated opiate dependence. Health Care Costs Although the general health status of people with opiate dependence is substantially worse than that of their contemporaries, they do not routinely use medical services. Typically, they seek medical care in hospital emergency rooms only after their medical conditions are seriously advanced. The consequences of untreated opiate dependence include much higher incidence of bacterial infections, including endocarditis, thrombophlebitis, and skin and soft tissue infections; tuberculosis; hepatitis B and C; AIDS and sexually transmitted diseases; and alcohol abuse. Because those who are

Guidelines 35

opiate-dependent present for medical care late in their diseases, medical care is generally more expensive. Health care costs related to opiate dependence have been estimated to be $1.2 billion per year. Joblessness Opiate dependence prevents many users from maintaining steady employment. Much of their time each day is spent in drug-seeking and drugtaking behavior. Therefore, many seek public assistance because they are unable to generate the income needed to support themselves and their families. Long-term outcome data show that opiate-dependent persons in MMT earn more than twice as much money annually as those not in treatment.

Outcomes of Pregnancy A substantial number of pregnant women dependent upon opiates also have HIV/AIDS. on the basis of preliminary data, women who receive MMT are more likely to be treated with zidovudine. It has been well established that administration of zidovudine to HIV-positive pregnant women reduces by two-thirds the rate of HIV transmission to their babies. Comprehensive MMT, along with sound prenatal care, has been shown to decrease obstetrical and fetal complications as well.

Current Treatment Modalities The Pharmacology of Commonly Prescribed Opiate Agonists and Antagonists The most frequently used agent in medically supervised opiate withdrawal and maintenance treatment is methadone. Methadone's half-life is approximately 24 hours and leads to a long duration of action and once-aday dosing. This feature, coupled with its slow onset of action, blunts its euphoric effect, making it unattractive as a principal drug of abuse. LAAM, a less commonly used opiate agonist, has a longer half-life and may prevent withdrawal symptoms for up to 96 hours. An emerging treatment option, buprenorphine , a partial opioid agonist, appears also to be effective for detoxification and maintenance.


Naltrexone is a non-addicting specific “mu” antagonist with a long half-life permitting once-a-day administration. It effectively blocks the cognitive and behavioral effects of opioids, and its prescription does not require special registration. The opioid-dependent person considering treatment should be informed of the availability of naltrexone maintenance treatment. However, in actively using opiate addicts, it produces immediate withdrawal symptoms with potentially serious effects. Medically-Supervised Withdrawal Methadone can also be used for detoxification. This can be accomplished over several weeks after a period of illicit opiate use or methadone maintenance. If methadone withdrawal is too rapid, abstinence symptoms are likely. They may lead the opiate-dependent person to illicit drug use and relapse into another cycle of abuse. Buprenorphine holds promise as an option for medically supervised withdrawal because its prolonged occupation of MU receptors attenuates withdrawal symptoms. More rapid detoxification options include use of opiate antagonists alone; the alpha-2 agonist clonidine alone; or clonidine followed by naltrexone. Clonidine reduces many of the autonomic signs and symptoms of opioid withdrawal. These strategies may be used in both inpatient and outpatient settings and allow medically supervised withdrawal from opioids in as little as 3 days. Most patients successfully complete detoxification using these strategies, but information concerning relapse rates is not available.

The Role of Psychosocial Treatments Non-pharmacologic supportive services are pivotal to successful MMT. The immediate introduction of these services as the opiate-dependent patient applies for MMT leads to significantly higher retention and more comprehensive and effective treatment. Comorbid psychiatric disorders require treatment. Other behavioral strategies have been successfully used in substance abuse treatment. Ongoing substance abuse counseling and other psychosocial therapies enhance program retention and positive outcome. Stable employment is an excellent predictor of clinical outcome. Therefore, vocational rehabilitation is a useful adjunct.

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Efficacy of Opiate Agonists It is now generally agreed that opiate dependence is a medical disorder and that pharmacologic agents are effective in its treatment. Evidence presented to the panel indicates that availability of these agents is severely limited and that large numbers of patients with this disorder have no access to treatment. The greatest experience with such agents has been with the opiate agonist methadone. Prolonged oral treatment with this medication diminishes and often eliminates opiate use, reduces transmission of many infections, including HIV and hepatitis B and C, and reduces criminal activity. Evidence is now accumulating that suggests the effectiveness in such patients of LAAM and buprenorphine. For more than 30 years, the daily oral administration of methadone has been used to treat tens of thousands of individuals dependent upon opiates in the United States and abroad. The effectiveness of MMT is dependent on many factors, including adequate dosage, duration plus continuity of treatment, and accompanying psychosocial services. A dose of 60 mg given once daily may achieve the desired treatment goal: abstinence from opiates. But higher doses are often required by many patients. Continuity of treatment is crucial-patients who are treated for less than 3 months generally show little or no improvement, and most, if not all, patients require continuous treatment over a period of years, and perhaps for life. Therefore, the program has come to be termed methadone “maintenance” treatment (MMT). Patient attributes that have sometimes been linked to better outcomes include older age, later age of dependence onset, lesser abuse of other substances including cocaine and alcohol, and lesser criminal activity. Recently, it has been reported that high motivation for change has been associated with positive outcomes. The effectiveness of MMT is often dependent on the involvement of a knowledgeable and empathetic staff and the availability of psychotherapy and other counseling services. The latter are especially important since individuals with opiate dependence are often afflicted with comorbid mental and personality disorders. Because methadone-treated patients generally are exposed to much less or no intravenous opiates, they are much less likely to transmit and contract HIV and hepatitis. This is especially important since recent data have shown that up to 75 percent of new instances of HIV infection are attributable to intravenous drug use. Since for many patients a major source of financing the opiate habit is criminal behavior, MMT generally leads to much less crime.


Although methadone is the primary opioid agonist used, other full and partial opioid agonists have been developed for treatment of opiate dependence. An analogue of methadone, levo-alpha acetyl-methadol (LAAM), has a longer half-life than methadone and so can be administered less frequently. A single dose of LAAM can prevent withdrawal symptoms and drug craving for 2 to 4 days. Buprenorphine, a recently developed partial opiate agonist, has the advantage over methadone that its discontinuation leads to much less severe withdrawal symptoms. The use of these medications is at an early stage, and it may be some time before their usefulness has been adequately evaluated.

Barriers to Effective Use of Opiate Agonists Misperceptions and Stigmas Many of the barriers to effective use of MMT in the treatment of opiate dependence stem from misperceptions and stigmas attached to opiate dependence, the people who are addicted, those who treat them, and the settings in which services are provided. Opiate-dependent persons are often perceived not as individuals with a disease, but as “other” or “different. “ Factors such as racism play a large role here but so does the popular image of dependence itself. Many people believe that dependence is self-induced or a failure of willpower and that efforts to treat it will inevitably fail. Vigorous and effective leadership is needed to inform the public that dependence is a medical disorder that can be effectively treated with significant benefits for the patient and society.

Increasing Availability of Effective Services Unfortunately, MMT programs are not readily available to all who could and wish to benefit from them. We as a society must make a commitment to offer effective treatment for opiate dependence to all who need it. Accomplishing that goal will require: ·

Making treatment as cost-effective as possible without sacrificing quality.

·

Increasing the availability and variety of treatment services.

·

Including and ensuring wider participation by physicians trained in substance abuse who will oversee the medical care.

·

Providing additional funding for opiate dependence treatments and coordinating these services with other necessary social services and medical care.

Guidelines 39

Training Physicians and Other Health Care Professionals One barrier to availability of MMT is the shortage of physicians and other health care professionals prepared to provide treatment for opiate dependence. All primary care medical specialties (including general practice, internal medicine, family practice, obstetrics and gynecology, geriatrics, pediatrics, and adolescent medicine) should be taught the principles of diagnosing and treating patients with opiate dependence. Nurses, social workers, psychologists, physician assistants, and other health care professionals should also be trained in these areas. The greater the number of trained physicians and other health care professionals, the greater the supply not only of professionals who can competently treat the opiate dependent but also of members of the community who are equipped to provide leadership and public education on these issues.

Reducing Unnecessary Regulation Of critical importance in improving MMT of opiate dependence is the recognition that, as in every other area of medicine, treatment must be tailored to the needs of the individual patient. Current Federal regulations make this difficult if not impossible. By prescribing MMT procedures in minute detail, FDA's regulations limit the flexibility and responsiveness of the programs, require unproductive paperwork, and impose administrative and oversight costs greater than those necessary for many patients. Yet these regulations seem to have little if any effect on quality of MMT care. We know of no other area where the Federal Government intrudes so deeply and coercively into the practice of medicine. For example, although providing a therapeutic dose is central to effective treatment and the therapeutic dose is now known to be higher than had previously been understood, FDA's regulations discourage such higher doses. However well-intended the FDA's treatment regulations were when written in 1972, they are no longer helpful. We recommend that these regulations be eliminated. Alternative means, such as accreditation, for improving quality of MMT programs should be instituted. The U.S. Department of Health and Human Services can more effectively, less coercively, and much more inexpensively discharge its statutory obligation to provide treatment guidance to MMT programs, physicians, and staff by means of publications, seminars, Web sites, continuing medical education, and the like. We also believe current laws and regulations should be revised to eliminate the extra level of regulation on methadone compared with other Schedule II narcotics. Currently, methadone can be dispensed only from facilities that obtain an extra license and comply with extensive extra regulatory


requirements. These extra requirements are unnecessary for a medication that is not often diverted for recreational or casual use but rather to individuals with opiate dependence who lack access to MMT programs. If extra levels of regulation were eliminated, many more physicians and pharmacies could prescribe and dispense methadone, making treatment available in many more locations than is now the case. Not every physician will choose to treat opiate-dependent persons, and not every methadonetreated person will prefer to receive services from an individual physician rather than to receive MMT in a clinic setting. But if some additional physicians and groups treat a few patients each, aggregate access to MMT would be expanded. We also believe that State and local regulations and enforcement efforts should be coordinated. We see little purpose to having separate State and Federal inspections of MMT programs. State and Federal regulators should coordinate their efforts, agree which programs each will inspect to avoid duplication, and target “poor performers” for the most intensive scrutiny while reducing scrutiny for MMT programs that consistently perform well. The States should address the problem of slow approval (at the State level) of FDA-approved medications. LAAM, for example, has not yet been approved by many States. States should harmonize their requirements with those of the Federal Government. We would expect these changes in the current regulatory system to reduce unnecessary costs both to MMT programs and to enforcement agencies at all levels. The savings could be used to treat more patients. In the end, an infusion of additional funding will be needed--funding sufficient to provide access to treatment for all who require treatment. We strongly recommend that legislators and regulators recognize that providing MMT is both cost-effective and compassionate and that it constitutes a health benefit that should be a component of public and private health care.

Future Research Areas The following questions may be answered through further research: ·

What initiates opiate use?

·

Define genetic predispositions?

·

Do some individuals take opiates to treat a preexisting disorder?

Guidelines 41

·

Which of the multiple psychological, sociological, and economic factors believed to predispose individuals to try opiates are most important as causative factors?

·

If the above are known, can one prevent opiate dependence?

·

What are the changes in the human brain that result in dependence when individuals repeatedly use opiates?

·

What are the underlying anatomical and neurophysiological substrates of craving?

·

What are the differences between individuals who can successfully terminate opiate dependence and those who cannot?

·

A scientifically credible national epidemiological study of the prevalence of opiate dependence in the United States is strongly recommended.

·

Rigorous study of the economic costs of opiate dependence in the United States and the cost-effectiveness of methadone maintenance therapy is also needed.

·

Longer-term follow-up studies of patients who complete rapid detoxification are necessary.

·

The feasibility of alternative routes of administration for agonist and antagonist therapy should be explored.

·

Systematic pharmacokinetic studies of methadone during MMT maintenance therapy are essential.

·

Physiologic factors that may influence adequate methadone dose in pregnant women need to be defined.

·

The effects of reduction of entitlement programs for those patients on MMT must be assessed.

·

The effects of the early and systematic introduction of rehabilitation services in MMT should be evaluated.

·

Variables that determine barriers must be defined.

·

Research on changing attitudes of the public, of health professionals, and of legislators is needed.

·

Research on improving educational methods for health professionals should be performed.

·

Research on prevention methods is necessary.

·

Research on efficacy of other opiate agonists/antagonists should be compared to that of methadone.


Conclusions and Recommendations The NIH Consensus recommends the following: ·

Vigorous and effective leadership is needed within the Office of National Drug Control Policy (ONDCP) (and related Federal and State agencies) to inform the public that dependence is a medical disorder that can be effectively treated with significant benefits for the patient and society.

·

Society must make a commitment to offering effective treatment for opiate dependence to all who need it.

·

The panel calls attention to the need for opiate-dependent persons under legal supervision to have access to MMT. The ONDCP and the U.S. Department of Justice should implement this recommendation.

·

The panel recommends improved training of physicians and other health care professionals in diagnosis and treatment of opiate dependence. For example, we encourage the National Institute on Drug Abuse and other agencies to provide funds to improve training for diagnosis and treatment of opiate dependence in medical schools.

·

The panel recommends that unnecessary regulation of MMT and all longacting agonist treatment programs be reduced.

·

Funding for MMT should be increased.

·

We advocate MMT as a benefit in public and private insurance programs, with parity of coverage for all medical and mental disorders.

·

We recommend targeting opiate-dependent pregnant women for MMT.

·

MMT must be culturally sensitive to enhance a favorable outcome for participating African American and Hispanic persons.

·

Patients, underrepresented minorities, and consumers should be included in bodies charged with policy development guiding opiate dependence treatment.

·

We recommend expanding the availability of opiate agonist treatment in those States and programs where this treatment option is currently unavailable.

More Guideline Sources The guideline above on heroin dependence is only one example of the kind of material that you can find online and free of charge. The remainder of this chapter will direct you to other sources which either publish or can help you find additional guidelines on topics related to heroin dependence. Many of

Guidelines 43

the guidelines listed below address topics that may be of particular relevance to your specific situation or of special interest to only some patients with heroin dependence. Due to space limitations these sources are listed in a concise manner. Do not hesitate to consult the following sources by either using the Internet hyperlink provided, or, in cases where the contact information is provided, contacting the publisher or author directly.

Topic Pages: MEDLINEplus For patients wishing to go beyond guidelines published by specific Institutes of the NIH, the National Library of Medicine has created a vast and patientoriented healthcare information portal called MEDLINEplus. Within this Internet-based system are “health topic pages.” You can think of a health topic page as a guide to patient guides. To access this system, log on to http://www.nlm.nih.gov/medlineplus/healthtopics.html. From there you can either search using the alphabetical index or browse by broad topic areas. If you do not find topics of interest when browsing health topic pages, then you can choose to use the advanced search utility of MEDLINEplus at http://www.nlm.nih.gov/medlineplus/advancedsearch.html. This utility is similar to the NIH Search Utility, with the exception that it only includes material linked within the MEDLINEplus system (mostly patient-oriented information). It also has the disadvantage of generating unstructured results. We recommend, therefore, that you use this method only if you have a very targeted search.

The Combined Health Information Database (CHID) CHID Online is a reference tool that maintains a database directory of thousands of journal articles and patient education guidelines on heroin dependence and related conditions. One of the advantages of CHID over other sources is that it offers summaries that describe the guidelines available, including contact information and pricing. CHID’s general Web site is http://chid.nih.gov/. To search this database, go to http://chid.nih.gov/detail/detail.html. In particular, you can use the advanced search options to look up pamphlets, reports, brochures, and information kits. The following was recently posted in this archive:


·

Narcotics: Drugs of Addiction Contact: Life Skills Education, 314 Washington St, Northfield, MN, 550572025, (507) 645-2994, http://www.lifeskillsed.com. Summary: This brochure defines the two types of narcotic drugs (opiates and synthetics) and explains that narcotics make the user less receptive to stimuli, by reducing their energy level, sex drive, and motivation to participate in daily life. The potency, effects, and consequences of heroin are summarized, followed by a definition of the levels of addiction, which include tolerance, psychological dependence, physical dependence, and addiction. The remainder of the booklet focuses on the negative physical, social, and emotional consequences of narcotics addiction, which include the increased likelihood of becoming infected with HIV through shared needles. It also offers treatment suggestions.

·

Heroin Gets Me Hard Contact: Center for Behavioral Research and Services, 1407 East 4th St, Long Beach, CA, 90802, (562) 495-2330. Summary: This flyer uses two personal stories -- those of Eddie, a Caucasian man, and A.J., a Black man -- to promote a message about the dangers of IV-needle sharing, and the importance of cleaning shared needles and using condoms to prevent HIV infection. It also contains several local news items pertinent to Long Beach, CA, and a cartoon about condom use.

The National Guideline Clearinghouse™ The National Guideline Clearinghouse™ offers hundreds of evidence-based clinical practice guidelines published in the United States and other countries. You can search their site located at http://www.guideline.gov by using the keyword “heroin dependence” or synonyms. The following was recently posted: ·

Substance abuse treatment for persons with HIV/AIDS. Source: Substance Abuse and Mental Health Services Administration (U.S.).; 2000; Various pagings http://www.guideline.gov/FRAMESETS/guideline_fs.asp?guideline=00 1770&sSearch_string=heroin+dependence

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Healthfinder™ Healthfinder™ is an additional source sponsored by the U.S. Department of Health and Human Services which offers links to hundreds of other sites that contain healthcare information. This Web site is located at http://www.healthfinder.gov. Again, keyword searches can be used to find guidelines. The following was recently found in this database: ·

Heroin: Abuse and Addiction Summary: This document is a compilation of scientific information on heroin. Source: National Institute on Drug Abuse, National Institutes of Health http://www.healthfinder.gov/scripts/recordpass.asp?RecordType=0&R ecordID=3789

The NIH Search Utility After browsing the references listed at the beginning of this chapter, you may want to explore the NIH Search Utility. This allows you to search for documents on over 100 selected Web sites that comprise the NIH-WEBSPACE. Each of these servers is “crawled” and indexed on an ongoing basis. Your search will produce a list of various documents, all of which will relate in some way to heroin dependence. The drawbacks of this approach are that the information is not organized by theme and that the references are often a mix of information for professionals and patients. Nevertheless, a large number of the listed Web sites provide useful background information. We can only recommend this route, therefore, for relatively rare or specific disorders, or when using highly targeted searches. To use the NIH search utility, visit the following Web page: http://search.nih.gov/index.html.

Additional Web Sources A number of Web sites that often link to government sites are available to the public. These can also point you in the direction of essential information. The following is a representative sample: ·

AOL: http://search.aol.com/cat.adp?id=168&layer=&from=subcats

·

drkoop.comÒ: http://www.drkoop.com/conditions/ency/index.html

·

Family Village: http://www.familyvillage.wisc.edu/specific.htm


·

Google: http://directory.google.com/Top/Health/Conditions_and_Diseases/

·

Med Help International: http://www.medhelp.org/HealthTopics/A.html

·

Open Directory Project: http://dmoz.org/Health/Conditions_and_Diseases/

·

Yahoo.com: http://dir.yahoo.com/Health/Diseases_and_Conditions/

·

WebMDÒHealth: http://my.webmd.com/health_topics

Vocabulary Builder The material in this chapter may have contained a number of unfamiliar words. The following Vocabulary Builder introduces you to terms used in this chapter that have not been covered in the previous chapter: Abortion: 1. the premature expulsion from the uterus of the products of conception - of the embryo, or of a nonviable fetus. The four classic symptoms, usually present in each type of abortion, are uterine contractions, uterine haemorrhage, softening and dilatation of the cervix, and presentation or expulsion of all or part of the products of conception. 2. premature stoppage of a natural or a pathological process. [EU] Amphetamine: A powerful central nervous system stimulant and sympathomimetic. Amphetamine has multiple mechanisms of action including blocking uptake of adrenergics and dopamine, stimulation of release of monamines, and inhibiting monoamine oxidase. Amphetamine is also a drug of abuse and a psychotomimetic. The l- and the d,l-forms are included here. The l-form has less central nervous system activity but stronger cardiovascular effects. The d-form is dextroamphetamine. [NIH] Analog: A chemical compound that is similar to another drug in its effects but differs slightly in its chemical structure. [NIH] Anatomical: Pertaining to anatomy, or to the structure of the organism. [EU] Antidote: A remedy for counteracting a poison. [EU] Antiviral: Destroying viruses or suppressing their replication. [EU] Anxiety: The unpleasant emotional state consisting of psychophysiological responses to anticipation of unreal or imagined danger, ostensibly resulting from unrecognized intrapsychic conflict. Physiological concomitants include increased heart rate, altered respiration rate, sweating, trembling, weakness, and fatigue; psychological concomitants include feelings of impending danger, powerlessness, apprehension, and tension. [EU]

Guidelines 47

Autonomic: Self-controlling; functionally independent. [EU] Barbiturate: A type of central nervous system (CNS) depressant often prescribed to promote sleep. [NIH] Benign: Not malignant; not recurrent; favourable for recovery. [EU] Benzodiazepine: A type of CNS depressant prescribed to relieve anxiety; among the most widely prescribed medications, including Valium and Librium. [NIH] Buprenorphine: A mixed opiate agonist/antagonist medication for the treatment of heroin addiction. [NIH] Cardiac: Pertaining to the heart. [EU] Cellulitis: An acute, diffuse, and suppurative inflammation of loose connective tissue, particularly the deep subcutaneous tissues, and sometimes muscle, which is most commonly seen as a result of infection of a wound, ulcer, or other skin lesions. [NIH] Chronic: Persisting over a long period of time. [EU] Cocaine: An alkaloid ester extracted from the leaves of plants including coca. It is a local anesthetic and vasoconstrictor and is clinically used for that purpose, particularly in the eye, ear, nose, and throat. It also has powerful central nervous system effects similar to the amphetamines and is a drug of abuse. Cocaine, like amphetamines, acts by multiple mechanisms on brain catecholaminergic neurons; the mechanism of its reinforcing effects is thought to involve inhibition of dopamine uptake. [NIH] Condoms: A sheath that is worn over the penis during sexual behavior in order to prevent pregnancy or spread of sexually transmitted disease. [NIH] Cortex: The outer layer of an organ or other body structure, as distinguished from the internal substance. [EU] Craving: A powerful, often uncontrollable desire for drugs. [NIH] Detoxification: A process of allowing the body to rid itself of a drug while managing the symptoms of withdrawal; often the first step in a drug treatment program. [NIH] Diarrhea: Passage of excessively liquid or excessively frequent stools. [NIH] Endocarditis: Exudative and proliferative inflammatory alterations of the endocardium, characterized by the presence of vegetations on the surface of the endocardium or in the endocardium itself, and most commonly involving a heart valve, but sometimes affecting the inner lining of the cardiac chambers or the endocardium elsewhere. It may occur as a primary disorder or as a complication of or in association with another disease. [EU] Epidemic: Occurring suddenly in numbers clearly in excess of normal expectancy; said especially of infectious diseases but applied also to any


disease, injury, or other health-related event occurring in such outbreaks. [EU] Epidemiological: Relating to, or involving epidemiology. [EU] Euphoria: An exaggerated feeling of physical and mental well-being, especially when not justified by external reality. Euphoria may be induced by drugs such as opioids, amphetamines, and alcohol and is also a feature of mania. [EU] Excitation: An act of irritation or stimulation or of responding to a stimulus; the addition of energy, as the excitation of a molecule by absorption of photons. [EU] Fentanyl: A medically useful opioid analog that is 50 times more potent than heroin. [NIH] Flushing: A transient reddening of the face that may be due to fever, certain drugs, exertion, stress, or a disease process. [NIH] Glucose: D-glucose, a monosaccharide (hexose), C6H12O6, also known as dextrose (q.v.), found in certain foodstuffs, especially fruits, and in the normal blood of all animals. It is the end product of carbohydrate metabolism and is the chief source of energy for living organisms, its utilization being controlled by insulin. Excess glucose is converted to glycogen and stored in the liver and muscles for use as needed and, beyond that, is converted to fat and stored as adipose tissue. Glucose appears in the urine in diabetes mellitus. [EU] Gynecology: A medical-surgical specialty concerned with the physiology and disorders primarily of the female genital tract, as well as female endocrinology and reproductive physiology. [NIH] Hepatitis: Inflammation of the liver. [EU] Homicide: The killing of one person by another. [NIH] Infusion: The therapeutic introduction of a fluid other than blood, as saline solution, solution, into a vein. [EU] Inhalation: The drawing of air or other substances into the lungs. [EU] Insomnia: Inability to sleep; abnormal wakefulness. [EU] Intramuscular: Within the substance of a muscle. [EU] Intravenous: Within a vein or veins. [EU] LAAM: An approved medication for the treatment of opioid addiction, taken 3 to 4 times a week. [NIH] Meperidine: A medically approved opioid available under various brand names (e.g., Demerol). [NIH] Methadone: A long-acting synthetic medication shown to be effective in treating heroin addiction. [NIH]

Guidelines 49

Molecular: Of, pertaining to, or composed of molecules : a very small mass of matter. [EU] Morphine: The principal alkaloid in opium and the prototype opiate analgesic and narcotic. Morphine has widespread effects in the central nervous system and on smooth muscle. [NIH] Mucosa: A mucous membrane, or tunica mucosa. [EU] Naloxone: A specific opiate antagonist that has no agonist activity. It is a competitive antagonist at mu, delta, and kappa opioid receptors. [NIH] Naltrexone: Derivative of noroxymorphone that is the N-cyclopropylmethyl congener of naloxone. It is a narcotic antagonist that is effective orally, longer lasting and more potent than naloxone, and has been proposed for the treatment of heroin addiction. The FDA has approved naltrexone for the treatment of alcohol dependence. [NIH] Narcotic: 1. pertaining to or producing narcosis. 2. an agent that produces insensibility or stupor, applied especially to the opioids, i.e. to any natural or synthetic drug that has morphine-like actions. [EU] Nausea: An unpleasant sensation, vaguely referred to the epigastrium and abdomen, and often culminating in vomiting. [EU] Neuronal: Pertaining to a neuron or neurons (= conducting cells of the nervous system). [EU] Obstetrics: A medical-surgical specialty concerned with management and care of women during pregnancy, parturition, and the puerperium. [NIH] Opiate: A remedy containing or derived from opium; also any drug that induces sleep. [EU] Opioids: Controlled drugs or narcotics most often prescribed for the management of pain; natural or synthetic chemicals based on opium's active component - morphine - that work by mimicking the actions of painrelieving chemicals produced in the body. [NIH] Overdose: 1. to administer an excessive dose. 2. an excessive dose. [EU] Parity: The number of offspring a female has borne. It is contrasted with GRAVIDITY, which refers to the number of pregnancies, regardless of outcome. [NIH] Pathogen: Any disease-producing microorganism. [EU] Pediatrics: A medical specialty concerned with maintaining health and providing medical care to children from birth to adolescence. [NIH] Pharmacologic: Pertaining to pharmacology or to the properties and reactions of drugs. [EU] Pneumonia: Inflammation of the lungs with consolidation. [EU]


Predisposition: A latent susceptibility to disease which may be activated under certain conditions, as by stress. [EU] Prenatal: Existing or occurring before birth, with reference to the fetus. [EU] Prevalence: The total number of cases of a given disease in a specified population at a designated time. It is differentiated from INCIDENCE, which refers to the number of new cases in the population at a given time. [NIH] Prisons: Penal institutions, or places of confinement for war prisoners. [NIH] Psychiatric: Pertaining to or within the purview of psychiatry. [EU] Psychiatry: The medical science that deals with the origin, diagnosis, prevention, and treatment of mental disorders. [NIH] Psychology: The science dealing with the study of mental processes and behavior in man and animals. [NIH] Psychotherapy: A generic term for the treatment of mental illness or emotional disturbances primarily by verbal or nonverbal communication. [NIH]

Pulmonary: Pertaining to the lungs. [EU] Receptor: 1. a molecular structure within a cell or on the surface characterized by (1) selective binding of a specific substance and (2) a specific physiologic effect that accompanies the binding, e.g., cell-surface receptors for peptide hormones, neurotransmitters, antigens, complement fragments, and immunoglobulins and cytoplasmic receptors for steroid hormones. 2. a sensory nerve terminal that responds to stimuli of various kinds. [EU] Saliva: The clear, viscous fluid secreted by the SALIVARY GLANDS and mucous glands of the mouth. It contains MUCINS, water, organic salts, and ptylin. [NIH] Sclerosis: A induration, or hardening; especially hardening of a part from inflammation and in diseases of the interstitial substance. The term is used chiefly for such a hardening of the nervous system due to hyperplasia of the connective tissue or to designate hardening of the blood vessels. [EU] Strychnine: An alkaloid found in the seeds of nux vomica. It is a competitive antagonist at glycine receptors and thus a convulsant. It has been used as an analeptic, in the treatment of nonketotic hyperglycinemia and sleep apnea, and as a rat poison. [NIH] Substrate: A substance upon which an enzyme acts. [EU] Surgical: Of, pertaining to, or correctable by surgery. [EU] Thrombophlebitis: formation. [EU]

Inflammation of a vein associated with thrombus

Tolerance: A condition in which higher doses of a drug are required to

Guidelines 51

produce the same effect as during initial use; often is associated with physical dependence. [NIH] Tomography: The recording of internal body images at a predetermined plane by means of the tomograph; called also body section roentgenography. [EU]

Tuberculosis: Any of the infectious diseases of man and other animals caused by species of mycobacterium. [NIH] Veins: The vessels carrying blood toward the heart. [NIH] Ventral: 1. pertaining to the belly or to any venter. 2. denoting a position more toward the belly surface than some other object of reference; same as anterior in human anatomy. [EU] Viruses: Minute infectious agents whose genomes are composed of DNA or RNA, but not both. They are characterized by a lack of independent metabolism and the inability to replicate outside living host cells. [NIH] Withdrawal: A variety of symptoms that occur after chronic use of some drugs is reduced or stopped. [NIH]

Seeking Guidance 53

CHAPTER 2. SEEKING GUIDANCE Overview Some patients are comforted by the knowledge that a number of organizations dedicate their resources to helping people with heroin dependence. These associations can become invaluable sources of information and advice. Many associations offer aftercare support, financial assistance, and other important services. Furthermore, healthcare research has shown that support groups often help people to better cope with their conditions.13 In addition to support groups, your physician can be a valuable source of guidance and support. Therefore, finding a physician that can work with your unique situation is a very important aspect of your care. In this chapter, we direct you to resources that can help you find patient organizations and medical specialists. We begin by describing how to find associations and peer groups that can help you better understand and cope with heroin dependence. The chapter ends with a discussion on how to find a doctor that is right for you.

Associations and Heroin Dependence As mentioned by the Agency for Healthcare Research and Quality, sometimes the emotional side of an illness can be as taxing as the physical side.14 You may have fears or feel overwhelmed by your situation. Everyone has different ways of dealing with disease or physical injury. Your attitude, your expectations, and how well you cope with your condition can all Churches, synagogues, and other houses of worship might also have groups that can offer you the social support you need. 14 This section has been adapted from http://www.ahcpr.gov/consumer/diaginf5.htm. 13


influence your well-being. This is true for both minor conditions and serious illnesses. For example, a study on female breast cancer survivors revealed that women who participated in support groups lived longer and experienced better quality of life when compared with women who did not participate. In the support group, women learned coping skills and had the opportunity to share their feelings with other women in the same situation. There are a number of directories that list additional medical associations that you may find useful. While not all of these directories will provide different information, by consulting all of them, you will have nearly exhausted all sources for patient associations.

The National Health Information Center (NHIC) The National Health Information Center (NHIC) offers a free referral service to help people find organizations that provide information about heroin dependence. For more information, see the NHIC’s Web site at http://www.health.gov/NHIC/ or contact an information specialist by calling 1-800-336-4797.

DIRLINE A comprehensive source of information on associations is the DIRLINE database maintained by the National Library of Medicine. The database comprises some 10,000 records of organizations, research centers, and government institutes and associations which primarily focus on health and biomedicine. DIRLINE is available via the Internet at the following Web site: http://dirline.nlm.nih.gov/. Simply type in “heroin dependence” (or a synonym) or the name of a topic, and the site will list information contained in the database on all relevant organizations. The Combined Health Information Database Another comprehensive source of information on healthcare associations is the Combined Health Information Database. Using the “Detailed Search” option, you will need to limit your search to “Organizations” and “heroin dependence”. Type the following hyperlink into your Web browser: http://chid.nih.gov/detail/detail.html. To find associations, use the drop boxes at the bottom of the search page where “You may refine your search by.” For publication date, select “All Years.” Then, select your preferred language and the format option “Organization Resource Sheet.” By making

Seeking Guidance 55

these selections and typing in “heroin dependence” (or synonyms) into the “For these words:” box, you will only receive results on organizations dealing with heroin dependence. You should check back periodically with this database since it is updated every 3 months. The National Organization for Rare Disorders, Inc. The National Organization for Rare Disorders, Inc. has prepared a Web site that provides, at no charge, lists of associations organized by specific diseases. You can access this database at the following Web site: http://www.rarediseases.org/cgi-bin/nord/searchpage. Select the option called “Organizational Database (ODB)” and type “heroin dependence” (or a synonym) in the search box.

Online Support Groups In addition to support groups, commercial Internet service providers offer forums and chat rooms for people with different illnesses and conditions. WebMDÒ, for example, offers such a service at their Web site: http://boards.webmd.com/roundtable. These online self-help communities can help you connect with a network of people whose concerns are similar to yours. Online support groups are places where people can talk informally. If you read about a novel approach, consult with your doctor or other healthcare providers, as the treatments or discoveries you hear about may not be scientifically proven to be safe and effective. The following internet links may be of particular interest: ·

KELY Support Group http://www.kely.org/kely_heroin.htm

·

Str8Life http://www.str8life.com/

Finding Drug Treatment and Alcohol Abuse Treatment Programs To find the right drug abuse treatment program or alcohol abuse treatment program for you, two useful resources are available.


National Drug and Treatment Referral Routing Service15 The U.S. Department of Health and Human Services (HHS) Substance Abuse and Mental Health Services Administration's (SAMHSA) National Drug and Treatment Referral Routing Service provides a toll-free telephone number for alcohol and drug information/treatment referral assistance. The number is: 1-800-662-HELP. When you call the toll-free number, a recorded message gives you the following options: 1 - Printed materials on alcohol and drug information or 24-hour substance abuse treatment referral information in your area (Additional options guide you through information and referral choices, including a Spanish language message.) 2 - Location of a Substance Abuse Treatment Office in your State

Substance Abuse Treatment Facility Locator16 Sponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA), this searchable directory of drug and alcohol treatment programs shows the location of facilities around the country that treat alcoholism, alcohol abuse and drug abuse problems (http://findtreatment.samhsa.gov/). The Locator includes more than 11,000 addiction treatment programs, including residential treatment centers, outpatient treatment programs, and hospital inpatient programs for drug addiction and alcoholism. Listings include treatment programs for marijuana, cocaine, and heroin addiction, as well as drug and alcohol treatment programs for adolescents, and adults. SAMHSA endeavors to keep the Locator current. All information in the Locator is completely updated each year, based on facility responses to SAMHSA's National Survey of Substance Abuse Treatment Services. New facilities are added monthly. Updates to facility names, addresses, and telephone numbers are made monthly, if facilities inform SAMHSA of changes. The search site is: http://findtreatment.samhsa.gov/facilitylocatordoc.htm.

15 16

Adapted from NIAAA: http://www.niaaa.nih.gov/other/referral.htm. Adapted from SAMHSA: http://findtreatment.samhsa.gov/.

Seeking Guidance 57

Finding Doctors One of the most important aspects of your treatment will be the relationship between you and your doctor or specialist. All patients with heroin dependence must go through the process of selecting a physician. While this process will vary from person to person, the Agency for Healthcare Research and Quality makes a number of suggestions, including the following:17 ·

If you are in a managed care plan, check the plan's list of doctors first.

·

Ask doctors or other health professionals who work with doctors, such as hospital nurses, for referrals.

·

Call a hospital’s doctor referral service, but keep in mind that these services usually refer you to doctors on staff at that particular hospital. The services do not have information on the quality of care that these doctors provide.

·

Some local medical societies offer lists of member doctors. Again, these lists do not have information on the quality of care that these doctors provide.

Additional steps you can take to locate doctors include the following: ·

Check with the associations listed earlier in this chapter.

·

Information on doctors in some states is available on the Internet at http://www.docboard.org. This Web site is run by “Administrators in Medicine,” a group of state medical board directors.

·

The American Board of Medical Specialties can tell you if your doctor is board certified. “Certified” means that the doctor has completed a training program in a specialty and has passed an exam, or “board,” to assess his or her knowledge, skills, and experience to provide quality patient care in that specialty. Primary care doctors may also be certified as specialists. The AMBS Web site is located at http://www.abms.org/newsearch.asp.18 You can also contact the ABMS by phone at 1-866-ASK-ABMS.

·

You can call the American Medical Association (AMA) at 800-665-2882 for information on training, specialties, and board certification for many licensed doctors in the United States. This information also can be found in “Physician Select” at the AMA's Web site: http://www.amaassn.org/aps/amahg.htm.

This section is adapted from the AHRQ: www.ahrq.gov/consumer/qntascii/qntdr.htm. While board certification is a good measure of a doctor's knowledge, it is possible to receive quality care from doctors who are not board certified. 17 18


If the previous sources did not meet your needs, you may want to log on to the Web site of the National Organization for Rare Disorders (NORD) at http://www.rarediseases.org/. NORD maintains a database of doctors with expertise in various rare diseases. The Metabolic Information Network (MIN), 800-945-2188, also maintains a database of physicians with expertise in various metabolic diseases.

Selecting Your Doctor19 When you have compiled a list of prospective doctors, call each of their offices. First, ask if the doctor accepts your health insurance plan and if he or she is taking new patients. If the doctor is not covered by your plan, ask yourself if you are prepared to pay the extra costs. The next step is to schedule a visit with your chosen physician. During the first visit you will have the opportunity to evaluate your doctor and to find out if you feel comfortable with him or her. Ask yourself, did the doctor: ·

Give me a chance to ask questions about heroin dependence?

·

Really listen to my questions?

·

Answer in terms I understood?

·

Show respect for me?

·

Ask me questions?

·

Make me feel comfortable?

·

Address the health problem(s) I came with?

·

Ask me my preferences about different kinds of treatments for heroin dependence?

·

Spend enough time with me?

Trust your instincts when deciding if the doctor is right for you. But remember, it might take time for the relationship to develop. It takes more than one visit for you and your doctor to get to know each other.

19 This

section has been adapted from the AHRQ: www.ahrq.gov/consumer/qntascii/qntdr.htm.

Seeking Guidance 59

Working with Your Doctor20 Research has shown that patients who have good relationships with their doctors tend to be more satisfied with their care and have better results. Here are some tips to help you and your doctor become partners: ·

You know important things about your symptoms and your health history. Tell your doctor what you think he or she needs to know.

·

It is important to tell your doctor personal information, even if it makes you feel embarrassed or uncomfortable.

·

Bring a “health history” list with you (and keep it up to date).

·

Always bring any medications you are currently taking with you to the appointment, or you can bring a list of your medications including dosage and frequency information. Talk about any allergies or reactions you have had to your medications.

·

Tell your doctor about any natural or alternative medicines you are taking.

·

Bring other medical information, such as x-ray films, test results, and medical records.

·

Ask questions. If you don't, your doctor will assume that you understood everything that was said.

·

Write down your questions before your visit. List the most important ones first to make sure that they are addressed.

·

Consider bringing a friend with you to the appointment to help you ask questions. This person can also help you understand and/or remember the answers.

·

Ask your doctor to draw pictures if you think that this would help you understand.

·

Take notes. Some doctors do not mind if you bring a tape recorder to help you remember things, but always ask first.

·

Let your doctor know if you need more time. If there is not time that day, perhaps you can speak to a nurse or physician assistant on staff or schedule a telephone appointment.

·

Take information home. Ask for written instructions. Your doctor may also have brochures and audio and videotapes that can help you.

This section has been adapted from the AHRQ: www.ahrq.gov/consumer/qntascii/qntdr.htm.

20


·

After leaving the doctor's office, take responsibility for your care. If you have questions, call. If your symptoms get worse or if you have problems with your medication, call. If you had tests and do not hear from your doctor, call for your test results. If your doctor recommended that you have certain tests, schedule an appointment to get them done. If your doctor said you should see an additional specialist, make an appointment.

By following these steps, you will enhance the relationship you will have with your physician.

Broader Health-Related Resources In addition to the references above, the NIH has set up guidance Web sites that can help patients find healthcare professionals. These include:21 ·

Caregivers: http://www.nlm.nih.gov/medlineplus/caregivers.html

·

Choosing a Doctor or Healthcare Service: http://www.nlm.nih.gov/medlineplus/choosingadoctororhealthcareserv ice.html

·

Hospitals and Health Facilities: http://www.nlm.nih.gov/medlineplus/healthfacilities.html

You can access this information at: http://www.nlm.nih.gov/medlineplus/healthsystem.html.

21

Clinical Trials 61

CHAPTER 3. CLINICAL TRIALS AND HEROIN DEPENDENCE Overview Very few medical conditions have a single treatment. The basic treatment guidelines that your physician has discussed with you, or those that you have found using the techniques discussed in Chapter 1, may provide you with all that you will require. For some patients, current treatments can be enhanced with new or innovative techniques currently under investigation. In this chapter, we will describe how clinical trials work and show you how to keep informed of trials concerning heroin dependence.

What Is a Clinical Trial?22 Clinical trials involve the participation of people in medical research. Most medical research begins with studies in test tubes and on animals. Treatments that show promise in these early studies may then be tried with people. The only sure way to find out whether a new treatment is safe, effective, and better than other treatments for heroin dependence is to try it on patients in a clinical trial.

What Kinds of Clinical Trials Are There? Clinical trials are carried out in three phases:

The discussion in this chapter has been adapted from the NIH and the NEI: www.nei.nih.gov/netrials/ctivr.htm.

22


·

Phase I. Researchers first conduct Phase I trials with small numbers of patients and healthy volunteers. If the new treatment is a medication, researchers also try to determine how much of it can be given safely.

·

Phase II. Researchers conduct Phase II trials in small numbers of patients to find out the effect of a new treatment on heroin dependence.

·

Phase III. Finally, researchers conduct Phase III trials to find out how new treatments for heroin dependence compare with standard treatments already being used. Phase III trials also help to determine if new treatments have any side effects. These trials--which may involve hundreds, perhaps thousands, of people--can also compare new treatments with no treatment. How Is a Clinical Trial Conducted?

Various organizations support clinical trials at medical centers, hospitals, universities, and doctors' offices across the United States. The “principal investigator” is the researcher in charge of the study at each facility participating in the clinical trial. Most clinical trial researchers are medical doctors, academic researchers, and specialists. The “clinic coordinator” knows all about how the study works and makes all the arrangements for your visits. All doctors and researchers who take part in the study on heroin dependence carefully follow a detailed treatment plan called a protocol. This plan fully explains how the doctors will treat you in the study. The “protocol” ensures that all patients are treated in the same way, no matter where they receive care. Clinical trials are controlled. This means that researchers compare the effects of the new treatment with those of the standard treatment. In some cases, when no standard treatment exists, the new treatment is compared with no treatment. Patients who receive the new treatment are in the treatment group. Patients who receive a standard treatment or no treatment are in the “control” group. In some clinical trials, patients in the treatment group get a new medication while those in the control group get a placebo. A placebo is a harmless substance, a “dummy” pill, that has no effect on heroin dependence. In other clinical trials, where a new surgery or device (not a medicine) is being tested, patients in the control group may receive a “sham treatment.” This treatment, like a placebo, has no effect on heroin dependence and does not harm patients.

Clinical Trials 63

Researchers assign patients “randomly” to the treatment or control group. This is like flipping a coin to decide which patients are in each group. If you choose to participate in a clinical trial, you will not know which group you will be appointed to. The chance of any patient getting the new treatment is about 50 percent. You cannot request to receive the new treatment instead of the placebo or sham treatment. Often, you will not know until the study is over whether you have been in the treatment group or the control group. This is called a “masked” study. In some trials, neither doctors nor patients know who is getting which treatment. This is called a “double masked” study. These types of trials help to ensure that the perceptions of the patients or doctors will not affect the study results. Natural History Studies Unlike clinical trials in which patient volunteers may receive new treatments, natural history studies provide important information to researchers on how heroin dependence develops over time. A natural history study follows patient volunteers to see how factors such as age, sex, race, or family history might make some people more or less at risk for heroin dependence. A natural history study may also tell researchers if diet, lifestyle, or occupation affects how a disease or disorder develops and progresses. Results from these studies provide information that helps answer questions such as: How fast will a disease or disorder usually progress? How bad will the condition become? Will treatment be needed? What Is Expected of Patients in a Clinical Trial? Not everyone can take part in a clinical trial for a specific disease or disorder. Each study enrolls patients with certain features or eligibility criteria. These criteria may include the type and stage of disease or disorder, as well as, the age and previous treatment history of the patient. You or your doctor can contact the sponsoring organization to find out more about specific clinical trials and their eligibility criteria. If you are interested in joining a clinical trial, your doctor must contact one of the trial's investigators and provide details about your diagnosis and medical history. If you participate in a clinical trial, you may be required to have a number of medical tests. You may also need to take medications and/or undergo surgery. Depending upon the treatment and the examination procedure, you may be required to receive inpatient hospital care. Or, you may have to return to the medical facility for follow-up examinations. These exams help


find out how well the treatment is working. Follow-up studies can take months or years. However, the success of the clinical trial often depends on learning what happens to patients over a long period of time. Only patients who continue to return for follow-up examinations can provide this important long-term information.

Recent Trials on Heroin Dependence The National Institutes of Health and other organizations sponsor trials on various diseases and disorders. Because funding for research goes to the medical areas that show promising research opportunities, it is not possible for the NIH or others to sponsor clinical trials for every disease and disorder at all times. The following lists recent trials dedicated to heroin dependence.23 If the trial listed by the NIH is still recruiting, you may be eligible. If it is no longer recruiting or has been completed, then you can contact the sponsors to learn more about the study and, if published, the results. Further information on the trial is available at the Web site indicated. Please note that some trials may no longer be recruiting patients or are otherwise closed. Before contacting sponsors of a clinical trial, consult with your physician who can help you determine if you might benefit from participation. ·

A Laboratory Model for Heroin Abuse Medications Condition(s): Substance-Related Disorders; Opioid-Related Disorders; Heroin Dependence Study Status: This study is currently recruiting patients. Sponsor(s): National Institute on Drug Abuse (NIDA); New York State Psychiatric Institute Purpose - Excerpt: To evaluate the effects of treatment medications (methadone, buprenorphine, LAAM, naltrexone, naltrexone microcapsules, and methoclocinnamox) on I.V. and smoked heroin selfadministration. Phase(s): Phase II Study Type: Treatment Contact(s): see Web site below Web Site: http://clinicaltrials.gov/ct/gui/show/NCT00000273

23

These are listed at www.ClinicalTrials.gov.

Clinical Trials 65

·

Buprenorphine/Naloxone versus Clonidine for INpatient Opiate Detoxification Condition(s): Heroin Dependence; Morphine Dependence; Substance Withdrawal Syndrome Study Status: This study is currently recruiting patients. Sponsor(s): National Institute on Drug Abuse (NIDA) Purpose - Excerpt: Buprenorphine/Naloxone versus Clonidine for Inpatient Opiate Detoxification Phase(s): Phase III Study Type: Treatment Contact(s): see Web site below Web Site: http://clinicaltrials.gov/ct/gui/show/NCT00032955

·

Buprenorphine/Naloxone versus Clonidine For Out-patient Opiate Detoxification Condition(s): Heroin Dependence; Morphine Dependence; Substance Withdrawal Syndrome Study Status: This study is currently recruiting patients. Sponsor(s): National Institute on Drug Abuse (NIDA) Purpose - Excerpt: Buprenorphine/Naloxone versus Clonidine For Outpatient Opiate Detoxification Phase(s): Phase III Study Type: Treatment Contact(s): see Web site below Web Site: http://clinicaltrials.gov/ct/gui/show/NCT00032968

·

Buprenorphine/Nx Tx of Heroin Dependence-A Compassionate Use Study Condition(s): Substance-Related Disorders; Heroin Dependence Study Status: This study is no longer recruiting patients. Sponsor(s): National Institute on Drug Abuse (NIDA); New York MDRU Purpose - Excerpt: Safety and Efficacy of burprenorphine/Naloxone in the treatment of opioid dependence - compassionate component. Phase(s): Phase III Study Type: Treatment


Contact(s): Svetlana Rybalova NY VAMC, Psychiatry (116-a) 423 East 23rd Street New York, New York, 11010, United States 1-212-686-7500 2686; New York; New York MDRU, VA Medical Center 423 East 23rd Street New York, New York, 10010, United States; Paul Casadonte 1-212686-7500 7985. Study chairs or principal investigators: John Rotrosen, Principal Investigator; New York MDRU VA Medical Center 423 East 23rd Street New York, New York, 10010, United States Web Site: http://clinicaltrials.gov/ct/gui/show/NCT00015340 ·

Activity Monitoring Assessment of Opiate Withdrawal Study Status: This study is completed. Sponsor(s): National Institute on Drug Abuse (NIDA); VA-Washington, DC Purpose - Excerpt: 1. To determine if hyperactivity accompanies abrupt opiate withdrawal in heroin addicts. 2. To determine if computerized solid state activity monitors are capable of quantifying hyperactivity. 3. To quantify the physical and affective symptoms occurring during abrupt withdrawal in heroin addicts and morphine's capacity to alleviate these symptoms. Phase(s): Phase II Contact(s): see Web site below Web Site: http://clinicaltrials.gov/ct/gui/show/NCT00000335

·

Buprenorphine/Naloxone Experiment II-2

Treatment

for

Opiod

Dependence-

Condition(s): Opioid-Related Disorders; Heroin Dependence Study Status: This study is terminated. Sponsor(s): National Institute on Drug Abuse (NIDA); University of Colorado Purpose - Excerpt: To assess the abuse liability and examine the reinforcing effects of intravenous buprenorphine and buprenorphine/naloxone combinations in heroin-dependent volunteers Phase(s): Phase II Study Type: Treatment Contact(s): see Web site below Web Site: http://clinicaltrials.gov/ct/gui/show/NCT00000330

Clinical Trials 67

·

Buprenorphine/Naloxone Experiment 1(1)

Treatment

for

Opioid

Dependence-

Condition(s): Opioid-Related Disorders; Heroin Dependence Study Status: This study is completed. Sponsor(s): National Institute on Drug Abuse (NIDA); University of Colorado Purpose - Excerpt: To assess the clinical efficacy of the buprenorphine/naloxone combination tablet for alternate-day dosing and determine whether multiples of the daily dose are necessary to maintain an effective alternate day dosing regimen. Phase(s): Phase II Study Type: Treatment Contact(s): see Web site below Web Site: http://clinicaltrials.gov/ct/gui/show/NCT00000326 ·

Buprenorphine/Naloxone Experiment I(2)

Treatment

for

Opioid

Dependence-

Condition(s): Opioid-Related Disorders; Heroin Dependence Study Status: This study is completed. Sponsor(s): National Institute on Drug Abuse (NIDA); University of Colorado Purpose - Excerpt: To compare the clinical efficacy of daily vs. 3-day (MWF) buprenorphine/naloxone combination tablet administration and determine whether outcomes are improved when using a 3-day schedule in which all doses are ingested at the clinic vs. one in which take-home doses are given on intervening days. Phase(s): Phase II Study Type: Treatment Contact(s): see Web site below Web Site: http://clinicaltrials.gov/ct/gui/show/NCT00000327 ·


Treatment

for

Opioid

Dependence-

Condition(s): Opioid-Related Disorders; Heroin Dependence Study Status: This study is completed. Sponsor(s): National Institute on Drug Abuse (NIDA); University of Colorado


Purpose - Excerpt: To assess the abuse liability and examine the reinforcing effects of intravenous buprenorphine and buprenorphine/naloxone combinations in buprenorphine-naloxone maintained volunteers Phase(s): Phase II Study Type: Treatment Contact(s): see Web site below Web Site: http://clinicaltrials.gov/ct/gui/show/NCT00000329 ·


Treatment

for

Opioid

Dependence-

Condition(s): Opioid-Related Disorders; Heroin Dependence Study Status: This study is terminated. Sponsor(s): National Institute on Drug Abuse (NIDA); University of Colorado Purpose - Excerpt: to assess the abuse liability and examine the reinforcing effects of intravenous buprenorphine and buprenorphine/naloxone combinations in healthy, non-drug dependenct volunteers Phase(s): Phase II Study Type: Treatment Contact(s): see Web site below Web Site: http://clinicaltrials.gov/ct/gui/show/NCT00000331 ·

Buprenorphine/Naloxone Experiment III)

Treatment

for

Opioid

Dependence-

Condition(s): Opioid-Related Disorders; Heroin Dependence Study Status: This study is completed. Sponsor(s): National Institute on Drug Abuse (NIDA); University of Colorado Purpose - Excerpt: To compare the clinical efficacy of the buprenorphine/naloxone combination tablet to methadone for opioid maintenance treatment. Phase(s): Phase II Study Type: Treatment Contact(s): see Web site below Web Site: http://clinicaltrials.gov/ct/gui/show/NCT00000328

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·

Clinical Rescue Protocol Condition(s): Opioid-Related Disorders Study Status: This study is completed. Sponsor(s): National Institute on Drug Abuse (NIDA) Purpose - Excerpt: 1) To detect increasing medication dose results in heroin cessation for patients still using. 2) To determine if decreasing medication dose in patients unable to tolerate medication dose increases retention. 3) To determine if blood levels of methadone or buprenorphine correlate with clinical response. Phase(s): Phase II Study Type: Treatment Contact(s): Walter Ling 10350 Santa Monica Blvd Suite 340 Los Angeles, California, 90025, United States 1-310-785-6665; California; Friends Research Institute, 10350 Santa Monica Blvd Suite 340 Los Angeles, California, 90025, United States; Walter Ling 1-310-785-6665. Study chairs or principal investigators: Walter Ling, Principal Investigator; Friends Research Institute 10350 Santa Monica Blvd Suite 340 Los Angeles, California, 90025, United States Web Site: http://clinicaltrials.gov/ct/gui/show/NCT00000206

·

Counseling Conditions for Thrice Weekly Buprenorphine in a Primary Care Clinic Condition(s): Opioid-Related Disorders; Heroin Dependence; Substance Abuse, Intravenous Study Status: This study is not yet open for patient recruitment. Sponsor(s): National Institute on Drug Abuse (NIDA); Yale University Purpose - Excerpt: Counseling for Buprenorphine in Primary Care Phase(s): Phase II Study Type: Treatment Contact(s): see Web site below Web Site: http://clinicaltrials.gov/ct/gui/show/NCT00023283

·

CS1008 A&B Eff/Safety trial of BUP/NX for the Tx of Opiate Dependence Condition(s): Substance-Related Disorders; Heroin Dependence Study Status: This study is completed. Sponsor(s): National Institute on Drug Abuse (NIDA); New York MDRU


Purpose - Excerpt: Safety and efficacy of buprenorphine/naloxone in treatment of opioid dependence. Phase(s): Phase III Study Type: Treatment Contact(s): Svetlana Rybalova NY VAMC, Psychiatry (116-a) 423 East 23rd Street New York, New York, 11010, United States 1-212-686-7500 2686; New York; New York MDRU, VA Medical Center 423 East 23rd Street New York, New York, 10010, United States; Paul Casadonte 1-212686-7500 7985. Study chairs or principal investigators: John Rotrosen, Principal Investigator; New York MDRU VA Medical Center 423 East 23rd Street New York, New York, 10010, United States Web Site: http://clinicaltrials.gov/ct/gui/show/NCT00015171 ·

Effects of Dynorphin 1-13 on Heroin Addiction Condition(s): Syndrome

Opioid-Related

Disorders;

Substance

Withdrawal

Study Status: This study is completed. Sponsor(s): National Institute on Drug Abuse (NIDA); University of Minnesota Purpose - Excerpt: Evaluate effects of IV dynorphin in humans during acute heroin abstinence, in order to determine that dynorphin suppresses acute opiate withdrawal, reduces opiate craving, and is safe at doses required to produce the above effects. Phase(s): Phase II Study Type: Treatment Contact(s): Paul Pentel Hennepin County Med Cntr, Dept of Med and Pharm 701 Park Ave Minneapolis, Minnesota, 55415, United States 1-612347-6426; Minnesota; U of Minnesota School of Medicine, 701 Park Avenue South Minneapolis, Minnesota, 55415, United States; Paul Pentel 1-612-347-6426. Study chairs or principal investigators: Paul Pentel, Principal Investigator; University of Minnesota 701 Park Avenue South Minneapolis, Minnesota, 55415, United States Web Site: http://clinicaltrials.gov/ct/gui/show/NCT00000244 ·

Evaluation of content & technical feasibility of a web-based education system for patients receiving office-based buprenorphine treatment Condition(s): Opioid-Related Disorders; Heroin Dependence Study Status: This study is not yet open for patient recruitment.

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Sponsor(s): National Institute on Drug Abuse (NIDA) Purpose - Excerpt: Applying Web Technology to Buprenorphine Treatment Study Type: Supportive Care Contact(s): Lisa A. Marsch HealthSim, Inc. 38 Fletcher Place Burlington, Vermont, 05401-1419, United States 1-802-656-9987 [email protected]; Vermont; University of Vermont, 38 Fletcher Place Burlington, Vermont, 5401, United States; Lisa A. Marsch 1-802-656-9987 [email protected]. Study chairs or principal investigators: Lisa A. Marsch, Principal Investigator; University of Vermont 38 Fletcher Place Burlington, Vermont, 5401, United States Web Site: http://clinicaltrials.gov/ct/gui/show/NCT00032253 ·

PK0496 Pharmacokinetics of Buprenorphine Condition(s): Opioid-Related Disorders; Heroin Dependence Study Status: This study is completed. Sponsor(s): National Institute on Drug Abuse (NIDA); New York MDRU Purpose - Excerpt: PK 0496 buprenorphine naloxone combination study. Phase(s): Phase I Study Type: Treatment Contact(s): Maria Taylor NY MDRU 79 Middleville Rd (151) Northport, New York, 11768, United States 1-516-261-4400 5630; New York; New York MDRU, VA Medical Center 423 East 23rd Street New York, New York, 10010, United States; Robert Hitzemann 1-516-444-2903. Study chairs or principal investigators: John Rotrosen, Principal Investigator; New York MDRU VA Medical Center 423 East 23rd Street New York, New York, 10010, United States Web Site: http://clinicaltrials.gov/ct/gui/show/NCT00015288

·

PK296 Bioavailability of Buprenorphine Sublingual Formulations Condition(s): Heroin Dependence Study Status: This study is terminated. Sponsor(s): National Institute on Drug Abuse (NIDA); New York MDRU Purpose - Excerpt: PK 0296 Buprenorphine Sublingual Formulation in Non-Dependenct Opiate Users Phase(s): Phase I Study Type: Treatment


Contact(s): Paul Casadonte New York MDRU, VA Medical Center 423 East 23rd Street New York, New York, 10010, United States 1-212-6867500 7985; New York; New York MDRU, VA Medical Center 423 East 23rd Street New York, New York, 10010, United States; Paul Casadonte 1212-686-7500 7985. Study chairs or principal investigators: John Rotrosen, Principal Investigator; New York MDRU VA Medical Center 423 East 23rd Street New York, New York, 10010, United States Web Site: http://clinicaltrials.gov/ct/gui/show/NCT00015184 ·

Treatment Efficacy for Drug Abuse and AIDS Prevention Condition(s): Cocaine-Related Disorders; Heroin Dependence Study Status: This study is completed. Sponsor(s): National Institute on Drug Abuse (NIDA); Mclean Hospital Purpose - Excerpt: Assessment of safety and effectiveness of buprenorphine for treatment of concurrent intravenous heroin and cocaine dependence. Phase(s): Phase II Study Type: Treatment Contact(s): Jack Mendelson McLean Hospital, Dept. of Psychiatry 115 Mill St Belmont, Massachusetts, 02178, United States 1-617-855-2716 [email protected]; Massachusetts; McLean Hospital, Dept. of Psychiatry, 115 Mill Street Belmont, Massachusetts, 2178, United States; Jack Mendelson 1-617-855-2716 [email protected]. Study chairs or principal investigators: Jack Mendelson, Principal Investigator; Mclean Hospital 115 Mill Street Belmont, Massachusetts, 2178, United States Web Site: http://clinicaltrials.gov/ct/gui/show/NCT00000211

Benefits and Risks24 What Are the Benefits of Participating in a Clinical Trial? If you are interested in a clinical trial, it is important to realize that your participation can bring many benefits to you and society at large: ·

A new treatment could be more effective than the current treatment for heroin dependence. Although only half of the participants in a clinical

This section has been adapted from ClinicalTrials.gov, a service of the National Institutes of Health: http://www.clinicaltrials.gov/ct/gui/c/a1r/info/whatis?JServSessionIdzone_ct=9jmun6f291. 24

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trial receive the experimental treatment, if the new treatment is proved to be more effective and safer than the current treatment, then those patients who did not receive the new treatment during the clinical trial may be among the first to benefit from it when the study is over. ·

If the treatment is effective, then it may improve health or prevent diseases or disorders.

·

Clinical trial patients receive the highest quality of medical care. Experts watch them closely during the study and may continue to follow them after the study is over.

·

People who take part in trials contribute to scientific discoveries that may help other people with heroin dependence. In cases where certain diseases or disorders run in families, your participation may lead to better care or prevention for your family members. The Informed Consent

Once you agree to take part in a clinical trial, you will be asked to sign an “informed consent.” This document explains a clinical trial's risks and benefits, the researcher’s expectations of you, and your rights as a patient.

What Are the Risks? Clinical trials may involve risks as well as benefits. Whether or not a new treatment will work cannot be known ahead of time. There is always a chance that a new treatment may not work better than a standard treatment. There is also the possibility that it may be harmful. The treatment you receive may cause side effects that are serious enough to require medical attention. How Is Patient Safety Protected? Clinical trials can raise fears of the unknown. Understanding the safeguards that protect patients can ease some of these fears. Before a clinical trial begins, researchers must get approval from their hospital's Institutional Review Board (IRB), an advisory group that makes sure a clinical trial is designed to protect patient safety. During a clinical trial, doctors will closely watch you to see if the treatment is working and if you are experiencing any side effects. All the results are carefully recorded and reviewed. In many cases, experts from the Data and Safety Monitoring Committee carefully


monitor each clinical trial and can recommend that a study be stopped at any time. You will only be asked to take part in a clinical trial as a volunteer giving informed consent. What Are a Patient's Rights in a Clinical Trial? If you are eligible for a clinical trial, you will be given information to help you decide whether or not you want to participate. As a patient, you have the right to: ·

Information on all known risks and benefits of the treatments in the study.

·

Know how the researchers plan to carry out the study, for how long, and where.

·

Know what is expected of you.

·

Know any costs involved for you or your insurance provider.

·

Know before any of your medical or personal information is shared with other researchers involved in the clinical trial.

·

Talk openly with doctors and ask any questions.

After you join a clinical trial, you have the right to: ·

Leave the study at any time. Participation is strictly voluntary. However, you should not enroll if you do not plan to complete the study.

·

Receive any new information about the new treatment.

·

Continue to ask questions and get answers.

·

Maintain your privacy. Your name will not appear in any reports based on the study.

·

Know whether you participated in the treatment group or the control group (once the study has been completed). What about Costs?

In some clinical trials, the research facility pays for treatment costs and other associated expenses. You or your insurance provider may have to pay for costs that are considered standard care. These things may include inpatient hospital care, laboratory and other tests, and medical procedures. You also may need to pay for travel between your home and the clinic. You should

Clinical Trials 75

find out about costs before committing to participation in the trial. If you have health insurance, find out exactly what it will cover. If you don't have health insurance, or if your insurance company will not cover your costs, talk to the clinic staff about other options for covering the cost of your care. What Questions Should You Ask before Deciding to Join a Clinical Trial? Questions you should ask when thinking about joining a clinical trial include the following: ·

What is the purpose of the clinical trial?

·

What are the standard treatments for heroin dependence? Why do researchers think the new treatment may be better? What is likely to happen to me with or without the new treatment?

·

What tests and treatments will I need? Will I need surgery? Medication? Hospitalization?

·

How long will the treatment last? How often will I have to come back for follow-up exams?

·

What are the treatment's possible benefits to my condition? What are the short- and long-term risks? What are the possible side effects?

·

Will the treatment be uncomfortable? Will it make me feel sick? If so, for how long?

·

How will my health be monitored?

·

Where will I need to go for the clinical trial? How will I get there?

·

How much will it cost to be in the study? What costs are covered by the study? How much will my health insurance cover?

·

Will I be able to see my own doctor? Who will be in charge of my care?

·

Will taking part in the study affect my daily life? Do I have time to participate?

·

How do I feel about taking part in a clinical trial? Are there family members or friends who may benefit from my contributions to new medical knowledge?

Keeping Current on Clinical Trials Various government agencies maintain databases on trials. The U.S. National Institutes of Health, through the National Library of Medicine, has


developed ClinicalTrials.gov to provide patients, family members, and physicians with current information about clinical research across the broadest number of diseases and conditions. The site was launched in February 2000 and currently contains approximately 5,700 clinical studies in over 59,000 locations worldwide, with most studies being conducted in the United States. ClinicalTrials.gov receives about 2 million hits per month and hosts approximately 5,400 visitors daily. To access this database, simply go to their Web site (www.clinicaltrials.gov) and search by “heroin dependence” (or synonyms). While ClinicalTrials.gov is the most comprehensive listing of NIH-supported clinical trials available, not all trials are in the database. The database is updated regularly, so clinical trials are continually being added. The following is a list of specialty databases affiliated with the National Institutes of Health that offer additional information on trials: ·

For clinical studies at the Warren Grant Magnuson Clinical Center located in Bethesda, Maryland, visit their Web site: http://clinicalstudies.info.nih.gov/

·

For clinical studies conducted at the Bayview Campus in Baltimore, Maryland, visit their Web site: http://www.jhbmc.jhu.edu/studies/index.html

·

For drug abuse trials, visit and search the Web site sponsored by the National Institute on Drug Abuse: http://www.nida.nih.gov/CTN/Index.htm

General References The following references describe clinical trials and experimental medical research. They have been selected to ensure that they are likely to be available from your local or online bookseller or university medical library. These references are usually written for healthcare professionals, so you may consider consulting with a librarian or bookseller who might recommend a particular reference. The following includes some of the most readily available references (sorted alphabetically by title; hyperlinks provide rankings, information and reviews at Amazon.com): ·

A Guide to Patient Recruitment : Today's Best Practices & Proven Strategies by Diana L. Anderson; Paperback - 350 pages (2001), CenterWatch, Inc.; ISBN: 1930624115; http://www.amazon.com/exec/obidos/ASIN/1930624115/icongroupinterna

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·

A Step-By-Step Guide to Clinical Trials by Marilyn Mulay, R.N., M.S., OCN; Spiral-bound - 143 pages Spiral edition (2001), Jones & Bartlett Pub; ISBN: 0763715697; http://www.amazon.com/exec/obidos/ASIN/0763715697/icongroupinterna

·

The CenterWatch Directory of Drugs in Clinical Trials by CenterWatch; Paperback - 656 pages (2000), CenterWatch, Inc.; ISBN: 0967302935; http://www.amazon.com/exec/obidos/ASIN/0967302935/icongroupinterna

·

The Complete Guide to Informed Consent in Clinical Trials by Terry Hartnett (Editor); Paperback - 164 pages (2000), PharmSource Information Services, Inc.; ISBN: 0970153309; http://www.amazon.com/exec/obidos/ASIN/0970153309/icongroupinterna

·

Dictionary for Clinical Trials by Simon Day; Paperback - 228 pages (1999), John Wiley & Sons; ISBN: 0471985961; http://www.amazon.com/exec/obidos/ASIN/0471985961/icongroupinterna

·

Extending Medicare Reimbursement in Clinical Trials by Institute of Medicine Staff (Editor), et al; Paperback 1st edition (2000), National Academy Press; ISBN: 0309068886; http://www.amazon.com/exec/obidos/ASIN/0309068886/icongroupinterna

·

Handbook of Clinical Trials by Marcus Flather (Editor); Paperback (2001), Remedica Pub Ltd; ISBN: 1901346293; http://www.amazon.com/exec/obidos/ASIN/1901346293/icongroupinterna

Vocabulary Builder The following vocabulary builder gives definitions of words used in this chapter that have not been defined in previous chapters: Bioavailability: The degree to which a drug or other substance becomes available to the target tissue after administration. [EU] Pharmacokinetics: The pattern of absorption, distribution, and excretion of a drug over time. [NIH] Sublingual: Located beneath the tongue. [EU]

79

PART II: ADDITIONAL RESOURCES AND ADVANCED MATERIAL

ABOUT PART II In Part II, we introduce you to additional resources and advanced research on heroin dependence. All too often, patients who conduct their own research are overwhelmed by the difficulty in finding and organizing information. The purpose of the following chapters is to provide you an organized and structured format to help you find additional information resources on heroin dependence. In Part II, as in Part I, our objective is not to interpret the latest advances on heroin dependence or render an opinion. Rather, our goal is to give you access to original research and to increase your awareness of sources you may not have already considered. In this way, you will come across the advanced materials often referred to in pamphlets, books, or other general works. Once again, some of this material is technical in nature, so consultation with a professional familiar with heroin dependence is suggested.

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CHAPTER 4. STUDIES ON HEROIN DEPENDENCE Overview Every year, academic studies are published on heroin dependence or related conditions. Broadly speaking, there are two types of studies. The first are peer reviewed. Generally, the content of these studies has been reviewed by scientists or physicians. Peer-reviewed studies are typically published in scientific journals and are usually available at medical libraries. The second type of studies is non-peer reviewed. These works include summary articles that do not use or report scientific results. These often appear in the popular press, newsletters, or similar periodicals. In this chapter, we will show you how to locate peer-reviewed references and studies on heroin dependence. We will begin by discussing research that has been summarized and is free to view by the public via the Internet. We then show you how to generate a bibliography on heroin dependence and teach you how to keep current on new studies as they are published or undertaken by the scientific community.

Federally-Funded Research on Heroin Dependence The U.S. Government supports a variety of research studies relating to heroin dependence and associated conditions. These studies are tracked by the Office of Extramural Research at the National Institutes of Health.25 Healthcare projects are funded by the National Institutes of Health (NIH), Substance Abuse and Mental Health Services (SAMHSA), Health Resources and Services Administration (HRSA), Food and Drug Administration (FDA), Centers for Disease Control 25


CRISP (Computerized Retrieval of Information on Scientific Projects) is a searchable database of federally-funded biomedical research projects conducted at universities, hospitals, and other institutions. Visit the CRISP Web site at http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket. You can perform targeted searches by various criteria including geography, date, as well as topics related to heroin dependence and related conditions. For most of the studies, the agencies reporting into CRISP provide summaries or abstracts. As opposed to clinical trial research using patients, many federally-funded studies use animals or simulated models to explore heroin dependence and related conditions. In some cases, therefore, it may be difficult to understand how some basic or fundamental research could eventually translate into medical practice. The following sample is typical of the type of information found when searching the CRISP database for heroin dependence: ·

Project Title: Molecular Genetics of Heroin Dependence Principal Investigator & Institution: Tsuang, Ming T.; Head and Professor; Massachusetts Mental Health Institute 74 Fenwood Rd Boston, Ma 02115 Timing: Fiscal Year 2002; Project Start 0-SEP-1999; Project End 8-FEB-2006 Summary: Our proposal is a response to NIDA's Request for Applications entitled `Molecular Genetics of Drug Addiction Vulnerability. The main goal of the proposed study is to detect one or more genes responsible for the genetic transmission of heroin dependence. Our Specific Aims respond to those specified in the RFA: 1) To collect and clinically characterize a large sib-pair sample with adequate statistical power for identifying genomic regions that may harbor loci conferring susceptibility to heroin dependence; 2) To conduct a whole-genome scan to establish the chromosomal localization of such loci; 3) To follow-up regions of interest from the whole-genome scan and evaluate candidate genes; and 4) To make the clinical and genotypic data quickly available to other investigators in the scientific community. To accomplish our aims, we have established a collaboration with two psychiatrists in Yunnan Province, China. This province, which borders the "Golden Triangle" -- the source of much of the world's heroin -- has a comprehensive drug abuse registration system to which our colleagues have access. About 30,000 heroin addicts are in the registry and can be easily located by our Chinese collaborator, the Director of the Yunnan Institute for Drug Abuse. We will collect blood and diagnostic

and Prevention (CDCP), Agency for Healthcare Research and Quality (AHRQ), and Office of Assistant Secretary of Health (OASH).

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information (using a structured diagnostic interview) from 1000 sib-pairs having DSM-IV defined heroin dependence as well as from their parents and other affected and unaffected siblings. Blood samples will be sent to a cell repository at Coriell Laboratories for creation of lymphoblastoid cell lines. In collaboration with a colleague at Washington University, we will complete a genome scan using 350 markers spaced at an average of 10 cM intervals. Genotype and clinical data will be entered using database software. We will conduct a multipoint linkage analysis using the guidelines of Lander and Kruglyak to assert statistical significance. We will follow-up regions of interest with a denser set of markers and evaluate candidate genes. All clinical data will be made available to the scientific community by the end of the funding period. All genotypes will be available one year after they are generated, but no later than a year after the end of the funding period. We are submitting this proposal using the RO1 mechanism. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket ·

Project Title: A Study of Anesthesia-Assisted Heroin Detoxification Principal Investigator & Institution: Kleber, Herbert D.; Director; New York State Psychiatric Institute 1051 Riverside Dr New York, Ny 10032 Timing: Fiscal Year 2000; Project Start 5-SEP-1999; Project End 1-AUG2002 Summary: Heroin dependence has reemerged as a significant public health problem in the 1990's, and with that, there has been renewed interest in improving methods of opioid detoxification. Detoxification is and will continue to be a common first step in the treatment of individuals with heroin dependence. During the past decade, there has been considerable popular attention focused on the utilization of general anesthesia during the acute phase of antagonist-precipitated opioid withdrawal, but there have been no controlled studies of anesthesiaassisted detoxification techniques. In particular, follow-up data on the patients detoxified under general anesthesia are not available. The research proposed here aims to compare anesthesia-assisted rapid opioid detoxification (AROD) with two alternative detoxification techniques, with attention both to acute measures of withdrawal and to longer-term abstinence and compliance with naltrexone maintenance. Our plan is to carry out a three-year study of 159 patients randomized to one of three detoxification techniques, followed by 12 weeks of outpatient treatment combining naltrexone maintenance and manual-guided relapse prevention/coping skills training psychotherapy. The AROD technique will be compared directly with a buprenorphine-mediated rapid opiate detoxification (BROD), and with a clonidine-assisted opioid


detoxification (COD). We incorporate comprehensive assessments of withdrawal severity and cognitive and motor performance, as well as follow-up data over 12 weeks. The strength of our approach lies in the controlled evaluation of the three detoxification techniques under consistent conditions. We expect to provide information about the safety and immediate- and intermediate-term efficacy of anesthesia-assisted detoxification from heroin. We believe that this information is very important for policy makers and patients, as anesthesia-assisted detoxification techniques have proliferated in this country and throughout the world, exposing patients to the costs and risks of anesthesia, without any evidence of improved outcome for the heroindependent individuals who choose anesthesia as a means to detoxification. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket ·

Project Title: Buprenorphine Abuse by Humans--Laboratory Studies Principal Investigator & Institution: Comer, Sandra D.; Associate Professor; New York State Psychiatric Institute 1051 Riverside Dr New York, Ny 10032 Timing: Fiscal Year 2000; Project Start 1-FEB-1999; Project End 1-JAN2003 Summary: Heroin use and treatment admissions for heroin dependence have been increasing steadily. Clearly, there is a need for new effective treatments for opioid dependence. Buprenorphine, a long-lasting, partial agonist at the mu subtype of opioid receptor, is one of the most promising new maintenance medications for heroin dependence. Buprenorphine's advantages are that: (1) only mild withdrawal effects develop upon discontinuation of use; (2) it may retain its therapeutic effectiveness when administered on an alternate-day, rather than a daily, schedule; and (3) it is generally well-accepted by patients. Despite these advantages, research indicates that buprenorphine may have abuse liability. Although it is commonly believed that the abuse potential of buprenorphine is low, numerous countries have reported illicit diversion of buprenorphine and a growing population of buprenorphine abusers. To date, no laboratory studies have evaluated the abuse liability of buprenorphine in humans using a drug selfadministration protocol, in which research volunteers are given the opportunity to take drug under controlled conditions. We are proposing to evaluate the abuse potential of buprenorphine in the laboratory, incorporating self-administration procedures with other measures of opioid effects. Physiological responses, subjects' verbal reports of drug effects, and learning and performance of a variety of computer tasks will also be measured. The

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studies will investigate the conditions under which buprenorphine may be self-administered in non- opioid-dependent individuals with a history of opioid abuse, as well as in opioid individuals. The aims of the proposed studies are to: (1) determine the conditions under which buprenorphine will serve as a reinforcer; (2) evaluate the abuse liability of the buprenorphine/naloxone combination, which is currently being developed to reduce illicit diversion of buprenorphine; (3) compare the reinforcing effects of buprenorphine with methadone, which is currently the most widely used maintenance medication for heroin dependence; and (4) assess buprenorphine selfadministration in participants maintained on different doses of morphine. This research will furnish useful information for clinicians treating heroin abusers, and importantly, will provide information about the effects of buprenorphine on multiple measures of human functioning, as well as actual buprenorphine use. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket ·

Project Title: Endogenous Opioids in Opiate Dependence Principal Investigator & Institution: Terenius, Lars Y.; ; University of Pennsylvania 3451 Walnut Philadelphia, Pa 19104 Timing: Fiscal Year 2000 Summary: The general aim of the program is to identify changes in the opioid peptide systems that are characteristic of opiate (heroin) dependence. The five- year program described here is concentrated on one of the three opioid peptide genes, prodynorphin. Pre-clinical evidence suggests that dynorphins are involved in opiate tolerance, dependence and withdrawal. Studies will be conducted in two general phases: 1. pre-clinical phase in which we will continue our studies of the mechanisms of tolerance and dependence using animal models and tissues and/or isolated cells of human origin and 2. clinical phase in which we will apply knowledge obtained in the pre- clinical phase to observe and measure indices of dynorphin activity during specific stages of the human addiction cycle and during electrostimulation procedures that have been reported to increase endogenous opioid activity. Naturally, as in any long-range proposal, the studies performed in years three to five may be different depending on findings in the earlier years. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket

·

Project Title: HIV Risk Reduction and Drug Abuse Treatment in Malaysia Principal Investigator & Institution: Schottenfeld, Richard S.; Professor; Psychiatry; Yale University New Haven, Ct 06520


Timing: Fiscal Year 2001; Project Start 0-SEP-2001; Project End 1-AUG2005 Summary: (provided by applicant): Combining drug abuse and HIV risk reduction counseling with opioid agonist maintenance treatment (OMT) or antagonist maintenance treatment with naltrexone (NMT) is effective for reducing illicit drug use and preventing HIV transmission associated with heroin dependence, but support for NMT remains tenuous and OMT is not currently available in many Western Pacific countries (e.g., Malaysia, Indonesia and Singapore) where heroin addiction and HIV infection are epidemic and closely linked with injection drug use (IDU) and high-risk sexual behaviors among addicts. Promising results of NMT in Malaysia have created interest in evaluating OMT using buprenorphine (BMT) and comparing the efficacy of counseling alone and counseling combined with BMT or NMT. We are proposing a 24week, randomized double blind clinical trial to evaluate the efficacy for maintaining abstinence and reducing HIV risk behaviors of manualguided, HIV risk reduction and drug counseling (DC-HIV) alone or when combined with BMT or NMT for recently detoxified and currently abstinent heroin dependent patients (N=l80) in Malaysia (Specific Aim 1). The study will allow evaluation of 3 hypotheses: DC-HIV plus naltrexone is superior to DC-HIV alone; DC-HIV plus buprenorphine is superior to DC-HIV alone; and DC-HIV plus naltrexone is superior to DC-HIV plus buprenorphine. Primary outcome measures, assessed by 3x/wk urine toxicology testing and self-report, include resumption of heroin use, 1 or 3 weeks continuous relapse and reductions in HIV risk behaviors. The project will also evaluate the characteristics of treatment-seeking heroin addicts in Malaysia (including specific risk behaviors and patterns of HIV risk behaviors; prevalence of psychiatric and other medical comorbidity; and patterns of social, family, vocational, and criminal activity and service needs--Specific Aim 2). This data will be used to revise the DCHIV manual to address the specific circumstances and risk behaviors of Malaysian heroin addicts. Finally, the project will also provide clinical training for health professionals and training and mentoring in drug abuse treatment and HIV prevention research to clinical researchers who will continue development, implementation, evaluation and dissemination of HIV prevention and drug abuse treatment approaches in Malaysia after the project ends (Specific Aim 3). The results of the study will inform government policy and support for HIV prevention and drug abuse treatment efforts in Malaysia and possibly also in other Western Pacific countries. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket

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·

Project Title: Laboratory Model for Heroin Abuse Medications Principal Investigator & Institution: Fischman, Marian W.; Professor of Behavioral Biology; New York State Psychiatric Institute 1051 Riverside Dr New York, Ny 10032 Timing: Fiscal Year 2000 Summary: Heroin use and treatment admissions for heroin dependence have been increasing steadily over the past several years. Clearly, there is a need for new effective treatments for opioid dependence. Although methadone, levo alpha-acetylmethadol (LAAM), and naltrexone are currently approved for the treatment of opioid dependence, many problems are associated with their use such as patient noncompliance, continued opioid use during treatment, and high relapse rates during withdrawal from treatment. Several possible causes for these problems have been suggested but insufficient research has been conducted to evaluate the effects of these medications on ongoing human behavior in a research laboratory setting. In the proposed research, participants residing in a controlled setting will be given the opportunity to work for heroin and money. These studies will examine the multiplicity of ways in which several current and proposed medications affect heroin consumption, performance, mood, physiological measures, and participants' verbal reports of drug effects. The model thus developed will be used to evaluate potential new medications for opioid abuse as they are developed and before they are put into large multi-center trials. The specific aims of the proposal are to evaluate: l) the effects of the combination tablet containing buprenorphine and naloxone; 2) the time course and efficacy of a depot formulation of naltrexone; 3) the ability of oral naltrexone maintenance to induce supersensitivity to the effects of heroin; and 4) the effects of memantine and dextromethorphan, which are low-affinity N-methyl-D-aspartate receptor antagonists. Several of these medications will also be evaluated in another project as adjunct medications for the treatment of withdrawal during detoxification from heroin. Together, data from these projects should shed light on the effects of these medications on a broad range of heroin's effects, from actual heroin taking to detoxification from heroin. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket

·

Project Title: Model for Screening Heroin Detoxification Medications Principal Investigator & Institution: Collins, Eric; ; New York State Psychiatric Institute 1051 Riverside Dr New York, Ny 10032 Timing: Fiscal Year 2000


Summary: Heroin dependence has reemerged as a significant public health problem in the 1990's. Detoxification is and will continue to be a common first step in the treatment of individuals with heroin dependence, but the two detoxification approaches in widespread use today, the methadone taper and clonidine-assisted detoxification, are flawed. There is a need for new pharmacological approaches to heroin detoxification. The research proposed here aims to develop and implement a model screening procedure to evaluate potentially promising new medications for use in heroin detoxification. Our approach is to carry out a series of three 7-day, three- arm randomized, double-blind clinical trials, each one comparing two matched promising medications for opioid detoxification with a clonidine- assisted detoxification. We incorporate a comprehensive assessment of withdrawal Severity, cognitive and motor performance, and follow-up data four weeks following entry into the study. Our first study compares two medications, a potentially less hypotensive alpha-2 agonist, lofexidine, and a calcium channel antagonist, isradipine, directly with clonidine-assisted detoxification. Our second trial examines the potential utility of NMDA antagonists by comparing two noncompetitive NMDA antagonists, memantine and dextromethorphan, with clonidine. The third trial investigates the role of partial mu opioid agonists with differential kappa activities by comparing buprenorphine and butorphanol with clonidine. The strength of our approach lies in the controlled evaluation of potentially promising detoxification medications under consistent conditions. We expect to provide information about new mechanisms for medications development for opioid detoxification. We focus on the role heroin detoxification procedures may have in maximizing the likelihood of opioid abstinence and treatment retention following detoxification. While we recognize that detoxification is only the first step in treatment, we also believe that improving this procedure could increase the number of heroin- dependent individuals entering it, completing it, and continuing after it with more definitive treatment. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket ·

Project Title: Maintenance

Neurobiology

of

Cognitive

Gains

with

Opiate

Principal Investigator & Institution: Forman, Steven D.; Psychiatry; University of Pittsburgh at Pittsburgh 4200 5Th Ave Pittsburgh, Pa 15260 Timing: Fiscal Year 2000; Project Start 1-MAY-1998; Project End 0-APR2003 Summary: (Applicant's Abstract) We propose a longitudinal study to monitor prefrontal cortical functioning in 56 heroin-dependent patients

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during the course of opiate maintenance. Using a newly developed variant of the Go/No Go task and functional magnetic resonance imaging (fMRI), we will assess whether prefrontal cortical activity increases with clinical improvement, both in dorsolateral regions associated with delay-dependent processing and in ventral areas associated with inhibitory processing. We will additionally use a combined fMRI/microdialysis system in a rat model to measure the neurochemical changes in those relevant brain areas identified in the clinical investigation. Heroin dependence remains a major public health problem in the United States. Opiate maintenance is the most effective treatment modality with an estimated 115,000 individuals currently receiving methadone maintenance (IOM Report, 1995). Despite its demonstrable effectiveness and widespread use, very little is known about the cognitive effects of chronic methadone. We know that opiate maintenance treatment allows opiate addicts to cease their relentless search for illicit opiates, accompanied by psychosocial stabilization in a number of domains including decreased criminal activity, increased productivity, increased employment and educational pursuits. Clinically, as the destabilized lifestyle of the addict is marked by impulsivity (by diagnostic definition), it appears apparent that clinical improvement must be accompanied by improvements in this cognitive characteristic. Opposition to opiate maintenance has always arisen from the view that opiate maintenance merely swaps one abused narcotic for another. From both a clinical and sociopolitical standpoint it is obviously relevant to establish that opiate maintenance treats a cognitive deficit induced by previous illicit opiate abuse. We have found no study addressing whether and how opiate maintenance affects impulsivity. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket ·

Project Title: Serotonin Function in Impulsive Opioid Dependent Pts Principal Investigator & Institution: Bickel, Warren; ; University of Vermont & St Agric College Burlington, Vt 05405 Timing: Fiscal Year 2000; Project Start 1-DEC-1977; Project End 8-FEB2001 Summary: This study will investigate the involvement of 5-stereonergic mechanisms in regulating delay discounting in opioid-dependent patients. In the first step we will determine the rate of discounting for hypothetical money and heroin in injection drug users in outpatient treatment for heroin dependence. In a second step we will determine whether serotonin is involved in the differences observed by administering a hormonal challenge test with the serotonergic probe citalopram to needle-sharers and non-sharers. The proposed research


may provide valuable information regarding the biological basis of addiction. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket

E-Journals: PubMed Central26 PubMed Central (PMC) is a digital archive of life sciences journal literature developed and managed by the National Center for Biotechnology Information (NCBI) at the U.S. National Library of Medicine (NLM).27 Access to this growing archive of e-journals is free and unrestricted.28 To search, go to http://www.pubmedcentral.nih.gov/index.html#search, and type “heroin dependence” (or synonyms) into the search box. This search gives you access to full-text articles. The following is a sample of items found for heroin dependence in the PubMed Central database: ·

Randomised trial of heroin maintenance programme for addicts who fail in conventional drug treatments by Thomas V Perneger, Francisco Giner, Miguel del Rio, and Annie Mino; 1998 July 4 http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=28595

The National Library of Medicine: PubMed One of the quickest and most comprehensive ways to find academic studies in both English and other languages is to use PubMed, maintained by the National Library of Medicine. The advantage of PubMed over previously mentioned sources is that it covers a greater number of domestic and foreign references. It is also free to the public.29 If the publisher has a Web site that offers full text of its journals, PubMed will provide links to that site, as well Adapted from the National Library of Medicine: http://www.pubmedcentral.nih.gov/about/intro.html. 27 With PubMed Central, NCBI is taking the lead in preservation and maintenance of open access to electronic literature, just as NLM has done for decades with printed biomedical literature. PubMed Central aims to become a world-class library of the digital age. 28 The value of PubMed Central, in addition to its role as an archive, lies the availability of data from diverse sources stored in a common format in a single repository. Many journals already have online publishing operations, and there is a growing tendency to publish material online only, to the exclusion of print. 29 PubMed was developed by the National Center for Biotechnology Information (NCBI) at the National Library of Medicine (NLM) at the National Institutes of Health (NIH). The PubMed database was developed in conjunction with publishers of biomedical literature as a search tool for accessing literature citations and linking to full-text journal articles at Web sites of participating publishers. Publishers that participate in PubMed supply NLM with their citations electronically prior to or at the time of publication. 26

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as to sites offering other related data. User registration, a subscription fee, or some other type of fee may be required to access the full text of articles in some journals. To generate your own bibliography of studies dealing with heroin dependence, simply go to the PubMed Web site at www.ncbi.nlm.nih.gov/pubmed. Type “heroin dependence” (or synonyms) into the search box, and click “Go.” The following is the type of output you can expect from PubMed for “heroin dependence” (hyperlinks lead to article summaries): ·

A multiple baseline analysis of treatment for heroin addiction. Author(s): Epstein LH, Parker FC, Jenkins CC. Source: Addictive Behaviors. 1976; 1(4): 327-30. No Abstract Available. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=998363&dopt=Abstract

Vocabulary Builder ACTH: Adrenocorticotropic hormone. [EU] Anesthesia: A state characterized by loss of feeling or sensation. This depression of nerve function is usually the result of pharmacologic action and is induced to allow performance of surgery or other painful procedures. [NIH]

Biochemical: Relating to biochemistry; characterized by, produced by, or involving chemical reactions in living organisms. [EU] Butorphanol: A synthetic morphinan analgesic with narcotic antagonist action. It is used in the management of severe pain. [NIH] Cerebrospinal: Pertaining to the brain and spinal cord. [EU] Chromosomal: Pertaining to chromosomes. [EU] Comorbidity: The presence of co-existing or additional diseases with reference to an initial diagnosis or with reference to the index condition that is the subject of study. Comorbidity may affect the ability of affected individuals to function and also their survival; it may be used as a prognostic indicator for length of hospital stay, cost factors, and outcome or survival. [NIH] Cortical: Pertaining to or of the nature of a cortex or bark. [EU] Dementia: A condition of deteriorated mentality. [NIH] Electroacupuncture: A form of acupuncture using low frequency electrically


stimulated needles to produce analgesia and anesthesia and to treat disease. [NIH]

Endogenous: Developing or originating within the organisms or arising from causes within the organism. [EU] Genotype: The genetic constitution of the individual; the characterization of the genes. [NIH] Hyperthermia: Abnormally high body temperature, especially that induced for therapeutic purposes. [EU] Hypotensive: Characterized by or causing diminished tension or pressure, as abnormally low blood pressure. [EU] LH: A small glycoprotein hormone secreted by the anterior pituitary. LH plays an important role in controlling ovulation and in controlling secretion of hormones by the ovaries and testes. [NIH] Localization: 1. the determination of the site or place of any process or lesion. 2. restriction to a circumscribed or limited area. 3. prelocalization. [EU] Locomotion: Movement or the ability to move from one place or another. It can refer to humans, vertebrate or invertebrate animals, and microorganisms. [NIH] Lumbar: Pertaining to the loins, the part of the back between the thorax and the pelvis. [EU] Memantine: Amantadine derivative that has some dopaminergic effects. It has been proposed as an antiparkinson agent. [NIH] Microdialysis: A technique for measuring extracellular concentrations of substances in tissues, usually in vivo, by means of a small probe equipped with a semipermeable membrane. Substances may also be introduced into the extracellular space through the membrane. [NIH] NMDA: N-methyl-D-aspartate, a chemical compound that reacts with glutamate receptors on nerve cells. [NIH] Prolactin: Pituitary lactogenic hormone. A polypeptide hormone with a molecular weight of about 23,000. It is essential in the induction of lactation in mammals at parturition and is synergistic with estrogen. The hormone also brings about the release of progesterone from lutein cells, which renders the uterine mucosa suited for the embedding of the ovum should fertilization occur. [NIH] Sensitization: 1. administration of antigen to induce a primary immune response; priming; immunization. 2. exposure to allergen that results in the development of hypersensitivity. 3. the coating of erythrocytes with antibody so that they are subject to lysis by complement in the presence of homologous antigen, the first stage of a complement fixation test. [EU] Serotonin: A neurotransmitter that causes a very broad range of effects on

Studies 93

perception, movement, and the emotions by modulating the actions of other neurotransmitters in most parts of the brain. [NIH] Stabilization: The creation of a stable state. [EU] Toxicity: The quality of being poisonous, especially the degree of virulence of a toxic microbe or of a poison. [EU] Toxicology: The science concerned with the detection, chemical composition, and pharmacologic action of toxic substances or poisons and the treatment and prevention of toxic manifestations. [NIH] Tremor: An involuntary trembling or quivering. [EU]

Books 95

CHAPTER 5. BOOKS ON HEROIN DEPENDENCE Overview This chapter provides bibliographic book references relating to heroin dependence. You have many options to locate books on heroin dependence. The simplest method is to go to your local bookseller and inquire about titles that they have in stock or can special order for you. Some patients, however, feel uncomfortable approaching their local booksellers and prefer online sources (e.g. www.amazon.com and www.bn.com). In addition to online booksellers, excellent sources for book titles on heroin dependence include the Combined Health Information Database and the National Library of Medicine. Once you have found a title that interests you, visit your local public or medical library to see if it is available for loan.

Book Summaries: Federal Agencies The Combined Health Information Database collects various book abstracts from a variety of healthcare institutions and federal agencies. To access these summaries, go directly to the following hyperlink: http://chid.nih.gov/detail/detail.html. You will need to use the “Detailed Search” option. To find book summaries, use the drop boxes at the bottom of the search page where “You may refine your search by.” Select the dates and language you prefer. For the format option, select “Monograph/Book.” Now type “heroin dependence” (or synonyms) into the “For these words:” box. You will only receive results on books. You should check back periodically with this database which is updated every 3 months. The following is a typical result when searching for books on heroin dependence:


·

Getting Tough on Gateway Drugs: A Guide for the Family Source: Washington, DC, American Psychiatric Press, 332 p., 1984. Contact: American Psychiatric Press, 1400 K Street, NW., Washington, DC 20005. (Available for Purchase). Summary: Getting Tough on Gateway Drugs: A Guide for the Family provides information to help parents prevent drug problems among their children and for parents of children who already have a drug problems and are seeking ways to solve these problems. Part One defines the nature of the Drug Dependence Syndrome. Part Two deals with three specific drugs: Marijuana, alcohol, and cocaine. The author selected these drugs for extensive discussion because they are gateway drugs to dependence on other drugs. Alcohol is the first psychoactive drug used by most American youth. The earlier and more intensively a young person uses alcohol, the more likely that person is to use other drugs. Marijuana use begins in the very early teens and is the primary gateway to all illegal drug use. Cocaine is singled out because of its recent rise to common use, its undeserved image as being safe, and because it has become a gateway drug to heroin addiction. Part Three discusses how families can prevent and treat drug problems, with special emphasis on interactions between parents and teenagers. This section also addresses how to make drug abuse treatment work and how self-help groups can be used effectively by individuals and families. The final chapter includes an annotated listing of additional readings and resources on drug dependence and strategies for prevention and treatment.

·

Killing the Ill? Heroin and AIDS in West Germany Source: Drug Policies in Western Europe. Contact: Max - Planck - Institut, Gunterdstalstrabe 73, Freiburg. Summary: This book chapter debates the merits of the Federal Republic of Germany's policy against methadone treatment for heroin users. The writer points out that although methadone treatment has proven extremely successful in other Western nations, allowing heroin addicts to break their injection habits and live healthier, more productive lives, the FRG government remains opposed to the treatment plan. The book chapter says that this not only condemns the Intravenous drug users (IVDU's) to less fulfilling lives and eventual death, it also contributes to the spread of Acquired immunodeficiency syndrome (AIDS). This happens in two ways: One, because more people are using needles, there are more people to share needles; and two, IVDU's on methadone prove more receptive to Human immunodeficiency virus (HIV) prevention information.

Books 97

·

Getting Tough on Gateway Drugs: A Guide for the Family Source: Washington, DC, American Psychiatric Press, 332 p., 1984. Contact: American Psychiatric Press, 1400 K Street, NW., Washington, DC 20005. (Available for Purchase). Summary: Getting Tough on Gateway Drugs: A Guide for the Family provides information to help parents prevent drug problems among their children and for parents of children who already have a drug problems and are seeking ways to solve these problems. Part One defines the nature of the Drug Dependence Syndrome. Part Two deals with three specific drugs: Marijuana, alcohol, and cocaine. The author selected these drugs for extensive discussion because they are gateway drugs to dependence on other drugs. Alcohol is the first psychoactive drug used by most American youth. The earlier and more intensively a young person uses alcohol, the more likely that person is to use other drugs. Marijuana use begins in the very early teens and is the primary gateway to all illegal drug use. Cocaine is singled out because of its recent rise to common use, its undeserved image as being safe, and because it has become a gateway drug to heroin addiction. Part Three discusses how families can prevent and treat drug problems, with special emphasis on interactions between parents and teenagers. This section also addresses how to make drug abuse treatment work and how self-help groups can be used effectively by individuals and families. The final chapter includes an annotated listing of additional readings and resources on drug dependence and strategies for prevention and treatment.

Book Summaries: Online Booksellers Commercial Internet-based booksellers, such as Amazon.com and Barnes & Noble.com, offer summaries which have been supplied by each title’s publisher. Some summaries also include customer reviews. Your local bookseller may have access to in-house and commercial databases that index all published books (e.g. Books in PrintÒ). The following have been recently listed with online booksellers as relating to heroin dependence (sorted alphabetically by title; follow the hyperlink to view more details at Amazon.com): ·

A Land Fit for Heroin: Drug Policies, Prevention , and Practice by Nicholas Dorn (Editor), Nigel South (Editor) (1987); ISBN: 0312012543; http://www.amazon.com/exec/obidos/ASIN/0312012543/icongroupin terna


·

Behind the Wall of Respect: Community Experiments in Heroin Addiction Control by Patrick H. Hughes (1977); ISBN: 0226359301; http://www.amazon.com/exec/obidos/ASIN/0226359301/icongroupin terna

·

Big Deal: The Politics of the Illicit Drugs Business by Anthony Henman, et al (1985); ISBN: 0745300081; http://www.amazon.com/exec/obidos/ASIN/0745300081/icongroupin terna

·

Children of Heroin Addicts by Barbara J. Sowder (1980); ISBN: 0030570336; http://www.amazon.com/exec/obidos/ASIN/0030570336/icongroupin terna

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Children of Heroin Addicts: An Assessment of Health, Learning, Behavioral, and Adjustment Problems (Praeger Studies in Issues and Research in Substance Abuse) by Barbara J. Sowder, et al (1980); ISBN: 0275905551; http://www.amazon.com/exec/obidos/ASIN/0275905551/icongroupin terna

·

Christiane F.: An Autobiography of a Child Prostitute and Heroin Addict by Christiane F. (1985); ISBN: 0553261371; http://www.amazon.com/exec/obidos/ASIN/0553261371/icongroupin terna

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Great Heroin Coup (1980); ISBN: 0896080315; http://www.amazon.com/exec/obidos/ASIN/0896080315/icongroupin terna

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Heroin Addiction: Treatment and Control in Britain by Edna Oppenheimer, Gerry V. Stimson (1982); ISBN: 0422778907; http://www.amazon.com/exec/obidos/ASIN/0422778907/icongroupin terna

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Heroin Addiction: What Americans Can Learn from the English Experience by Horace Freeland. Judson (1975); ISBN: 0394720172; http://www.amazon.com/exec/obidos/ASIN/0394720172/icongroupin terna

·

Heroin and Politicians: The Failure of Public Policy to Control Addiction in America (Contributions in Political Science) by David J. Bellis (1982); ISBN: 0313225575; http://www.amazon.com/exec/obidos/ASIN/0313225575/icongroupin terna

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Heroin Stimulus: Implications for a Theory of Addiction by R. E. Meyer, S. M. Mirin (1979); ISBN: 0306401045;

Books 99

http://www.amazon.com/exec/obidos/ASIN/0306401045/icongroupin terna ·

Heroin Triangle by Michael Mastantuono (1978); ISBN: 0416002919; http://www.amazon.com/exec/obidos/ASIN/0416002919/icongroupin terna

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Heroin, Deviance and Morality (1980); ISBN: 0803915500; http://www.amazon.com/exec/obidos/ASIN/0803915500/icongroupin terna

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Heroin: Addiction and Treatment: Medical Subject Analysis and Research Index With Bibliography by Mary Rebecca Barton (1983); ISBN: 0881640468; http://www.amazon.com/exec/obidos/ASIN/0881640468/icongroupin terna

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'It's So Good, Don't Even Try It Once': Heroin in Perspective. by David Elvin, Smith (1972); ISBN: 0135065844; http://www.amazon.com/exec/obidos/ASIN/0135065844/icongroupin terna

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Kick Heroin: For Those Concerned With Addiction by Liz Cutland (1983); ISBN: 0946551200; http://www.amazon.com/exec/obidos/ASIN/0946551200/icongroupin terna

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Life With Heroin (1985); ISBN: 0669103039; http://www.amazon.com/exec/obidos/ASIN/0669103039/icongroupin terna

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Life With Heroin: Voices from the Inner City by Bill Hanson (1985); ISBN: 0669099333; http://www.amazon.com/exec/obidos/ASIN/0669099333/icongroupin terna

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Narcomania: On Heroin by Marek Kohn (1987); ISBN: 057114506X; http://www.amazon.com/exec/obidos/ASIN/057114506X/icongroupi nterna

·

Pathways from Heroin Addiction: Recovery Without Treatment (Health, Society, and Policy) by Patrick Biernacki (1986); ISBN: 0877224102; http://www.amazon.com/exec/obidos/ASIN/0877224102/icongroupin terna

·

Pathways from Heroin Addiction: Recovery Without Treatment (Health, Society, and Policy) by Patrick Biernacki (1986); ISBN: 0877224102;


http://www.amazon.com/exec/obidos/ASIN/0877224102/icongroupin terna ·

Red Heroin by Jerry Pournelle (1985); ISBN: 0441710891; http://www.amazon.com/exec/obidos/ASIN/0441710891/icongroupin terna

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Ripping and Running: A Formal Ethnography of Urban Heroin Addicts by Michael Agar (1973); ISBN: 0127850201; http://www.amazon.com/exec/obidos/ASIN/0127850201/icongroupin terna

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Taking Care of Business: The Economics of Crime by Heroin Abusers by Bruce Johnson (1985); ISBN: 0669095354; http://www.amazon.com/exec/obidos/ASIN/0669095354/icongroupin terna

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The American Heroin Empire: Power, Profits, and Politics by Richard Kunnes (1973); ISBN: 0396066976; http://www.amazon.com/exec/obidos/ASIN/0396066976/icongroupin terna

·

The De-Addiction Process: Studies in the De-Addiction of Confirmed Heroin Addicts. by Leon. Brill (1972); ISBN: 0398025320; http://www.amazon.com/exec/obidos/ASIN/0398025320/icongroupin terna

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The Hardest Drug (1985); ISBN: 0226424278; http://www.amazon.com/exec/obidos/ASIN/0226424278/icongroupin terna

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The Hardest Drug: Heroin and Public Policy (Studies in Crime and Justice Series) by John Kaplan (1985); ISBN: 0226424286; http://www.amazon.com/exec/obidos/ASIN/0226424286/icongroupin terna

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The Heroin Connection (Cobra, No 1) by Joseph R. Rosenberger (1986); ISBN: 1555471234; http://www.amazon.com/exec/obidos/ASIN/1555471234/icongroupin terna

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The Heroin Merchants by Vic Phillips (1985); ISBN: 0825302528; http://www.amazon.com/exec/obidos/ASIN/0825302528/icongroupin terna

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The Heroin Solution by Arnold S. Trebach (1982); ISBN: 0300027737; http://www.amazon.com/exec/obidos/ASIN/0300027737/icongroupin terna

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The Heroin Trail by Rinehart and W New York : Holt (1975); ISBN: 0030138418; http://www.amazon.com/exec/obidos/ASIN/0030138418/icongroupin terna

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The Pleasant Avenue Connection by David. Durk (1977); ISBN: 0060111429; http://www.amazon.com/exec/obidos/ASIN/0060111429/icongroupin terna

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The Politics of Heroin in Southeast Asia by Alfred W. McCoy (1972); ISBN: 0060129018; http://www.amazon.com/exec/obidos/ASIN/0060129018/icongroupin terna

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The Virtues of Hell by Pierre Boulle (1974); ISBN: 081490744X; http://www.amazon.com/exec/obidos/ASIN/081490744X/icongroupi nterna

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Women and Heroin Abuse: A Survey of Sexism in Drug Abuse Administration by Debra L. Ashbrook (1979); ISBN: 0882475568; http://www.amazon.com/exec/obidos/ASIN/0882475568/icongroupin terna

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Women on Heroin by Marsha Rosenbaum (1981); ISBN: 0813509467; http://www.amazon.com/exec/obidos/ASIN/0813509467/icongroupin terna

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Young People and Heroin: An Examination of Heroin Use in the North of England: A Report to the Health Education Council by Geoffrey Pearson, et al (1987); ISBN: 0566053888; http://www.amazon.com/exec/obidos/ASIN/0566053888/icongroupin terna

·

Young People and Heroin: An Examination of Heroin Use in the North of England: A Report to the Health Education Council by Geoffrey Pearson, et al (1987); ISBN: 0566053888; http://www.amazon.com/exec/obidos/ASIN/0566053888/icongroupin terna

The National Library of Medicine Book Index The National Library of Medicine at the National Institutes of Health has a massive database of books published on healthcare and biomedicine. Go to the following Internet site, http://locatorplus.gov/, and then select “Search LOCATORplus.” Once you are in the search area, simply type “heroin


dependence” (or synonyms) into the search box, and select “books only.” From there, results can be sorted by publication date, author, or relevance. The following was recently catalogued by the National Library of Medicine:30 ·

Age of initiation to heroin use: cohort trends and consequences of early initiation for subsequent adjustment. Author: Michael Lynskey & Wayne Hall; Year: 1998; [New South Wales]: National Drug and Alcohol Research Centre, 1998; ISBN: 0947229973

·

Assessing the population level impact of the Swiss model of heroin prescription. Author: Wayne Hall; Year: 1999; [Sydney]: NDARC, c1999; ISBN: 0733406238

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Benzodiazepine dependence and psychopathology amond heroin users in Sydney. Author: Joanne Ross & Shane Darke; Year: 1997; Sydney: National Drug & Alcohol Research Centre, University of New South Wales, c1997; ISBN: 0947229809

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Benzodiazepine use among heroin users in Sydney: transitions between routes of administration. Author: Joanne Ross, Shane Darke & Wayne Hall; Year: 1996; Sydney: National Drug and Alcohol Research Centre, University of New South Wales, c1996; ISBN: 0947229574

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Changes in heroin availability in Sydney Australia in early 2001. Author: David Rouen ... [et al.]; Year: 2001; Sydney: National Drug and Alcohol Research Centre, University of New South Wales c2001; ISBN: 0733417833

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Concepts in managing alcohol and drug abuse. Author: Barry Stimmel, editor; Year: 1995; New York: Haworth Medical Press, 1995

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Cost-benefit analysis of heroin maintenance treatment. Author: volume editors, Felix Gutzwiller, Thomas Steffen; Year: 2000; Basel; New York: Karger, 2000; ISBN: 3805568746 (hardcover: alk. paper) http://www.amazon.com/exec/obidos/ASIN/3805568746/icongroupin terna

·

Creating the American junkie: addiction research in the classic era of narcotic control. Author: Caroline Jean Acker; Year: 2002; Baltimore:

In addition to LOCATORPlus, in collaboration with authors and publishers, the National Center for Biotechnology Information (NCBI) is adapting biomedical books for the Web. The books may be accessed in two ways: (1) by searching directly using any search term or phrase (in the same way as the bibliographic database PubMed), or (2) by following the links to PubMed abstracts. Each PubMed abstract has a “Books” button that displays a facsimile of the abstract in which some phrases are hypertext links. These phrases are also found in the books available at NCBI. Click on hyperlinked results in the list of books in which the phrase is found. Currently, the majority of the links are between the books and PubMed. In the future, more links will be created between the books and other types of information, such as gene and protein sequences and macromolecular structures. See http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=Books.

30

Books 103

Johns Hopkins University Press, 2002; ISBN: 0801867983 (hardcover: alk. paper) http://www.amazon.com/exec/obidos/ASIN/0801867983/icongroupin terna ·

Effective medical treatment of heroin addiction: January 1994 through September 1997 plus selected earlier citations: 941 citations. Author: prepared by Mary E. Conway, James R. Cooper; Year: 1997; Bethesda, Md.: U.S. Dept. of Health and Human Services, Public Health Service, National Institutes of Health, National Library of Medicine, Reference Section, [1997]

·

Ethnographic study of heroin abuse by Mexican Americans in San Antonio, Texas. Author: Reyes Ramos; Year: 1995; Austin, Tex.: Texas Commission on Alcohol and Drug Aubse, [1995]

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Heroin addicts in Texas: the nature and size of a hidden population. Author: by Jane Carlisle Maxwell; Year: 1999; Austin, Tex.: Texas Commission on Alcohol and Drug Abuse, c1999

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Heroin century. Author: Tom Carnwath and Ian Smith; Year: 2002; London; New York: Routledge, 2002; ISBN: 0415278716 (hbk) http://www.amazon.com/exec/obidos/ASIN/0415278716/icongroupin terna

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Heroin in the age of crack-cocaine. Author: James A. Inciardi, Lana D. Harrison, editors; Year: 1998; Thousand Oaks: Sage Publications, c1998; ISBN: 0761904239 (cloth: alk. paper) http://www.amazon.com/exec/obidos/ASIN/0761904239/icongroupin terna

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Heroin overdose: prevalence, correlates, consequences and interventions. Author: Matthew Warner-Smith, ... [et al.]; Year: 2000; Australia: National Drug and Alcohol Research Centre, University of New South Waltes, 2000; ISBN: 0733407994

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Heroin purity and composition: an analysis of street-level samples in Cabramatta, NSW. Author: Wendy Swift, Lisa Maher, and Michael Dawson; Year: 1999; [Sydney]: NDARC, c1999; ISBN: 0733406580

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Heroin use in Sydney's Indo-Chinese communities: a review of NDARC research. Author: Lisa Maher and Wendy Swift; Year: 1997; [Sydney?]: National Drug and Alcohol Research Centre, University of New South Wales, 1997; ISBN: 0947229760

·

Heroin-related deaths in New South Wales: 1992-1996. Author: Shane Darke ... [et al.]; Year: 1999; Sydney: National Drug & Alcohol Research Centre, University of New South Wales, c1999; ISBN: 0733404774


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How many dependent opioid users are there in Australia? Author: Wayne Hall ... [et al.]; Year: 2000; [Kensington, N.S.W.]: National Drug and Alcohol Research Centre, c2000; ISBN: 0733407110

·

International criticism of the Swiss heroin trials: report of the External Expert Committee of the WHO statements of the UN International Narcotics Control Board (INCB). Author: [editors, Swiss Physicians against Drugs and AIDS Information Switzerland]; Year: 1999; Zürich: Swiss Physicians against Drugs and AIDS Information Switzerland, 1999; ISBN: 3952154660

·

Manual for economic data collection in pharmacotherapy trials for heroin dependence. Author: Elena Gospodarevskaya, Anthony Harris; Year: 2000; West Heidelberg, Australia: Centre for Health Program Evaluation, [2000]; ISBN: 1876662263

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Methadone in the treatment of narcotic addiction. Author: Andrew J. Byrne; Year: 1995; Redfern, NSW: Tosca Press, c1995; ISBN: 0646248707

·

NIH Consensus Development Conference on Effective Medical Treatment of Heroin Addiction: November 17-19, 1997, William H. Natcher Conference Center, National Institutes of Health, Bethesda, Md. Author: sponsored by the National Institute on Drug Abuse and the; Year: 1997; Bethesda, Md.: National Institutes of Health, Continuing Medical Education, 1997

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Prescription of narcotics for heroin addicts: main results of the Swiss National Cohort Study. Author: A. Uchtenhagen ... [et al.]; Year: 1999; Basel; New York: Karger, 1999; ISBN: 380556791X (hardcover: alk. paper) http://www.amazon.com/exec/obidos/ASIN/380556791X/icongroupi nterna

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Rio Arriba County strategy to combat heroin addiction [microform]: hearing before a subcommittee of the Committee on Appropriations, United States Senate, One Hundred Sixth Congress, first session, special hearing. Author: United States. Congress. Senate. Committee on Appropriations. Subcommittee on Commerce, Justice, State, the Judiciary, and Related Agencies; Year: 1999; Washington: U.S. G.P.O.: For sale by the U.S. G.P.O., Supt. of Docs., Congressional Sales Office, 1999; ISBN: 0160587042

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Running the risks: heroin, health, and harm in south west Sydney. Author: Lisa Maher ... [et al.]; Year: 1998; [Sydney, N.S.W.?]: National Drug and Alcohol Research Centre, University of New South Wales, 1998; ISBN: 0947229922

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Surviving heroin: interviews with women in methadone clinics. Author: Jennifer Friedman and Marixsa Alicea; Year: 2001; Gainesville: University Press of Florida, c2001; ISBN: 081302286X (cloth: alk. paper)

Books 105

http://www.amazon.com/exec/obidos/ASIN/081302286X/icongroupi nterna ·

Toxicological findings and circumstances of heroin-related deaths in South Western Sydney, 1995. Author: Shane Darke, Deborah Zador, & Sandra Sunjic; Year: 1997; [Sydney]: National Drug and Alcohol Research Centre, 1997; ISBN: 0947229655

·

Transitions between the injection of heroin and amphetamines. Author: Shane Darke, Sharlene Kaye & Joanne Ross; Year: 1998; [New South Wales]: National Drug and Alcohol Research Centre, University of New South Wales, c1998

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Under the influence of the market: an applied study of illicitly selling and consuming heroin. Author: Anne Line Bretteville-Jensen, Matthew Sutton; Year: 1996; York: University of York, Centre for Health Economics, [1996]

Chapters on Heroin Dependence Frequently, heroin dependence will be discussed within a book, perhaps within a specific chapter. In order to find chapters that are specifically dealing with heroin dependence, an excellent source of abstracts is the Combined Health Information Database. You will need to limit your search to book chapters and heroin dependence using the “Detailed Search” option. Go directly to the following hyperlink: http://chid.nih.gov/detail/detail.html. To find book chapters, use the drop boxes at the bottom of the search page where “You may refine your search by.” Select the dates and language you prefer, and the format option “Book Chapter.” By making these selections and typing in “heroin dependence” (or synonyms) into the “For these words:” box, you will only receive results on chapters in books.

General Home References In addition to references for heroin dependence, you may want a general home medical guide that spans all aspects of home healthcare. The following list is a recent sample of such guides (sorted alphabetically by title; hyperlinks provide rankings, information, and reviews at Amazon.com): · Drugs (Health Issues) by Sarah Lennard-Brown; Library Binding - 64 pages (March 2002), Raintree/Steck Vaughn; ISBN: 0739847732; http://www.amazon.com/exec/obidos/ASIN/0739847732/icongroupinterna


· The Encyclopedia of Drugs and Alcohol (Reference) by Greg Roza; School & Library Binding - 199 pages (September 2001); Franklin Watts, Incorporated; ISBN: 0531118991; http://www.amazon.com/exec/obidos/ASIN/0531118991/icongroupinterna

Vocabulary Builder Agar: A complex sulfated polymer of galactose units, extracted from Gelidium cartilagineum, Gracilaria confervoides, and related red algae. It is used as a gel in the preparation of solid culture media for microorganisms, as a bulk laxative, in making emulsions, and as a supporting medium for immunodiffusion and immunoelectrophoresis. [NIH] Crack: Short term for a smokable form of cocaine. [NIH] Psychopathology: The study of significant causes and processes in the development of mental illness. [NIH]

Multimedia 107

CHAPTER 6. MULTIMEDIA ON HEROIN DEPENDENCE Overview Information on heroin dependence can come in a variety of formats. Among multimedia sources, video productions, slides, audiotapes, and computer databases are often available. In this chapter, we show you how to keep current on multimedia sources of information on heroin dependence. We start with sources that have been summarized by federal agencies, and then show you how to find bibliographic information catalogued by the National Library of Medicine. If you see an interesting item, visit your local medical library to check on the availability of the title.

Bibliography: Multimedia on Heroin Dependence The National Library of Medicine is a rich source of information on healthcare-related multimedia productions including slides, computer software, and databases. To access the multimedia database, go to the following Web site: http://locatorplus.gov/. Select “Search LOCATORplus.” Once in the search area, simply type in heroin dependence (or synonyms). Then, in the option box provided below the search box, select “Audiovisuals and Computer Files.” From there, you can choose to sort results by publication date, author, or relevance. The following multimedia has been indexed on heroin dependence. For more information, follow the hyperlink indicated: · ·

Brain pathways : the heart of drug dependence. Source: Jeffrey Fortuna; Year: 2001; Format: Videorecording; Ashland, OR : CNS Productions, c2001 Chasing the dragon : heroin addiction. Source: GWC; Year: 1997; Format: Videorecording; Cahokia, IL: GWC, c1997


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Chemical dependence : releasing the hostage within. Source: Nimco; produced by St. Mary's Medical Center; Year: 1995; Format: Videorecording; Ashland, OR : CNS Productions, c2001 Co-dependence : the joy of recovery. Source: [presented by] Johnson Institute; filmed by Gannett Production Services; Year: 1988; Format: Videorecording; Minneapolis: The Institute, c1988 Constant craving : the science of addiction. Source: a presentation of Films for the Humanities & Sciences, BBC; Year: 2001; Format: Videorecording; Princeton, N.J.: Films for the Humanities & Sciences, c2001 Dealing with the demon. Source: the Australian Film Finance Corporation presents an Aspire Films production; Year: 1996; Format: Videorecording; New York: First Run/Icarus Films, c1996 Drug epidemic. Source: Psychodynamic Research Corporation, in association with Medi-Tel Communications; Year: 1975; Format: Videorecording; Spring Valley, N. Y.: Blue Hill Educational Systems, c1975 From opium to heroin. Source: produced by Cinemed, in cooperation with the Haight-Ashbury Drug Detoxification, Rehabilitation, and Aftercare Project; Year: 1988; Format: Videorecording; Ashland, OR: CINEMED, c1988 Getting off heroin with methadone . Year: 1995; Format: Videorecording; [Toronto, Ont.]: Elan Productions, 1995 Heroin : black tar magic, China white death. Source: Visions Video Productions; Year: 1992; Format: Videorecording; [Evanston, Ill.]: Visions Video Production, c1992 Heroin : from pleasure to pain. Source: [presented by] CNS Productions, Inc., in cooperation with the Haight-Ashbury Drug Detox Clinic; Year: 1999; Format: Videorecording; Ashland, OR: CNS Productions, c1999 Heroin and other opiates. Source: [presented by] Gary Whiteaker Corporation; Year: 1989; Format: Videorecording; Belleville, Ill.: The Corporation, [1989] Issues in treatment of anxiety : drug use, dependence, abuse and addiction. Source: [presented by] Marshfield Clinic, Saint Joseph's Hospital, [and] Marshfield Medical Research Foundation; Year: 1992; Format: Videorecording; Marshfield, WI: Marshfield Regional Video Network, [1992] LAAM : another treatment option for opiate addiction. Source: National Institute on Drug Abuse; produced by Issembert Productions; Year: 1995; Format: Videorecording; [Rockville, Md.?]: NCADI, [1995]

Multimedia 109

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Methadone : curse or cure? Source: [presented by] Filmakers Library, Inc; Year: 1994; Format: Videorecording; New York, N.Y.: Filmakers Library, [1994] Methadone : where we are. Source: produced by Issembert Productions [and] NIDA; Year: 1993; Format: Videorecording; [Rockville, Md.]: National Institute on Drug Abuse, [1993] Preventing drug abuse. Source: a presentation for Films for the Humanities & Sciences; Year: 2000; Format: Videorecording; Princeton, N.J.: Films for the Humanities & Sciences, c2000 Substance abuse : alcoholism and drug dependence. Source: Veterans Administration; Communications by Design; VAH Brentwood, Los Angeles; Year: 1980; Format: Videorecording; Washington, D.C.: National Audiovisual Center, [1980] Substance abuse & nutrition. Source: NHV, National Health Video Inc; Year: 1997; Format: Videorecording; Los Angeles, CA: National Health Video, c1997 Substance dependence. Source: Medcom, Inc; Year: 1985; Format: Filmstrip; Garden Grove, Calif.: Medcom, c1985

Vocabulary Builder Opium: The air-dried exudate from the unripe seed capsule of the opium poppy, Papaver somniferum, or its variant, P. album. It contains a number of alkaloids, but only a few - morphine, codeine, and papaverine - have clinical significance. Opium has been used as an analgesic, antitussive, antidiarrheal, and antispasmodic. [NIH]

Physician Guidelines and Databases 111

CHAPTER 7. PHYSICIAN GUIDELINES AND DATABASES Overview Doctors and medical researchers rely on a number of information sources to help patients with their conditions. Many will subscribe to journals or newsletters published by their professional associations or refer to specialized textbooks or clinical guides published for the medical profession. In this chapter, we focus on databases and Internet-based guidelines created or written for this professional audience.

NIH Guidelines For the more common diseases, The National Institutes of Health publish guidelines that are frequently consulted by physicians. Publications are typically written by one or more of the various NIH Institutes. For physician guidelines, commonly referred to as “clinical” or “professional” guidelines, you can visit the following Institutes: ·

Office of the Director (OD); guidelines consolidated across agencies available at http://www.nih.gov/health/consumer/conkey.htm

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National Institute of General Medical Sciences (NIGMS); fact sheets available at http://www.nigms.nih.gov/news/facts/

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National Library of Medicine (NLM); extensive encyclopedia (A.D.A.M., Inc.) with guidelines: http://www.nlm.nih.gov/medlineplus/healthtopics.html

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National Institute on Drug Abuse (NIDA); guidelines available at http://www.nida.nih.gov/DrugAbuse.html


NIH Databases In addition to the various Institutes of Health that publish professional guidelines, the NIH has designed a number of databases for professionals.31 Physician-oriented resources provide a wide variety of information related to the biomedical and health sciences, both past and present. The format of these resources varies. Searchable databases, bibliographic citations, full text articles (when available), archival collections, and images are all available. The following are referenced by the National Library of Medicine:32 ·

Bioethics: Access to published literature on the ethical, legal and public policy issues surrounding healthcare and biomedical research. This information is provided in conjunction with the Kennedy Institute of Ethics located at Georgetown University, Washington, D.C.: http://www.nlm.nih.gov/databases/databases_bioethics.html

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HIV/AIDS Resources: Describes various links and databases dedicated to HIV/AIDS research: http://www.nlm.nih.gov/pubs/factsheets/aidsinfs.html

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NLM Online Exhibitions: Describes “Exhibitions in the History of Medicine”: http://www.nlm.nih.gov/exhibition/exhibition.html. Additional resources for historical scholarship in medicine: http://www.nlm.nih.gov/hmd/hmd.html

·

Biotechnology Information: Access to public databases. The National Center for Biotechnology Information conducts research in computational biology, develops software tools for analyzing genome data, and disseminates biomedical information for the better understanding of molecular processes affecting human health and disease: http://www.ncbi.nlm.nih.gov/

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Population Information: The National Library of Medicine provides access to worldwide coverage of population, family planning, and related health issues, including family planning technology and programs, fertility, and population law and policy: http://www.nlm.nih.gov/databases/databases_population.html

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Cancer Information: Access to caner-oriented databases: http://www.nlm.nih.gov/databases/databases_cancer.html

Remember, for the general public, the National Library of Medicine recommends the databases referenced in MEDLINEplus (http://medlineplus.gov/ or http://www.nlm.nih.gov/medlineplus/databases.html). 32 See http://www.nlm.nih.gov/databases/databases.html. 31


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Profiles in Science: Offering the archival collections of prominent twentieth-century biomedical scientists to the public through modern digital technology: http://www.profiles.nlm.nih.gov/

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Chemical Information: Provides links to various chemical databases and references: http://sis.nlm.nih.gov/Chem/ChemMain.html

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Clinical Alerts: Reports the release of findings from the NIH-funded clinical trials where such release could significantly affect morbidity and mortality: http://www.nlm.nih.gov/databases/alerts/clinical_alerts.html

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Space Life Sciences: Provides links and information to space-based research (including NASA): http://www.nlm.nih.gov/databases/databases_space.html

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MEDLINE: Bibliographic database covering the fields of medicine, nursing, dentistry, veterinary medicine, the healthcare system, and the pre-clinical sciences: http://www.nlm.nih.gov/databases/databases_medline.html

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Toxicology and Environmental Health Information (TOXNET): Databases covering toxicology and environmental health: http://sis.nlm.nih.gov/Tox/ToxMain.html

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Visible Human Interface: Anatomically detailed, three-dimensional representations of normal male and female human bodies: http://www.nlm.nih.gov/research/visible/visible_human.html

While all of the above references may be of interest to physicians who study and treat heroin dependence, the following are particularly noteworthy.

The Combined Health Information Database A comprehensive source of information on clinical guidelines written for professionals is the Combined Health Information Database. You will need to limit your search to “Brochure/Pamphlet,” “Fact Sheet,” or “Information Package” and heroin dependence using the “Detailed Search” option. Go directly to the following hyperlink: http://chid.nih.gov/detail/detail.html. To find associations, use the drop boxes at the bottom of the search page where “You may refine your search by.” For the publication date, select “All Years,” select your preferred language, and the format option “Fact Sheet.” By making these selections and typing “heroin dependence” (or synonyms) into the “For these words:” box above, you will only receive results on fact sheets dealing with heroin dependence. The following is a sample result:


·

Hey! What's Goin' Down? Well There's Crack, Heroin, Cocaine, Dilaudid, and a New Flag is Going Up! It's HIV Contact: Oklahoma State Department of Health, Disease & Prevention Services, HIV/STD Service, 1000 NE 10th St, Oklahoma City, OK, 731171299, (405) 271-4636, http://www.health.state.ok.us/program/hivstd/index.html. Summary: This brochure uses comic book style lettering and illustrations to tell readers about Human immunodeficiency virus (HIV) and Acquired immunodeficiency syndrome (AIDS). It informs readers that sharing needles can be fatal because HIV is easily transmitted that way. Readers are cautioned not to share needles, or at least to clean needles and syringes with household bleach and rinse with water. They are told that having sex with anyone carrying the virus is dangerous, and the greater the number of sex partners, the greater the danger. The use of latex condoms and nonoxynol 9 is recommended. The brochure states that HIV is not transmitted by doorknobs, toilet seats, mosquitoes, drinking glasses, telephones, or swimming pools.

The NLM Gateway33 The NLM (National Library of Medicine) Gateway is a Web-based system that lets users search simultaneously in multiple retrieval systems at the U.S. National Library of Medicine (NLM). It allows users of NLM services to initiate searches from one Web interface, providing “one-stop searching” for many of NLM's information resources or databases.34 One target audience for the Gateway is the Internet user who is new to NLM's online resources and does not know what information is available or how best to search for it. This audience may include physicians and other healthcare providers, researchers, librarians, students, and, increasingly, patients, their families, and the public.35 To use the NLM Gateway, simply go to the search site at Adapted from NLM: http://gateway.nlm.nih.gov/gw/Cmd?Overview.x. The NLM Gateway is currently being developed by the Lister Hill National Center for Biomedical Communications (LHNCBC) at the National Library of Medicine (NLM) of the National Institutes of Health (NIH). 35 Other users may find the Gateway useful for an overall search of NLM's information resources. Some searchers may locate what they need immediately, while others will utilize the Gateway as an adjunct tool to other NLM search services such as PubMed® and MEDLINEplus®. The Gateway connects users with multiple NLM retrieval systems while also providing a search interface for its own collections. These collections include various types of information that do not logically belong in PubMed, LOCATORplus, or other established NLM retrieval systems (e.g., meeting announcements and pre-1966 journal citations). The Gateway will provide access to the information found in an increasing number of NLM retrieval systems in several phases. 33 34


http://gateway.nlm.nih.gov/gw/Cmd. Type “heroin dependence” (or synonyms) into the search box and click “Search.” The results will be presented in a tabular form, indicating the number of references in each database category. Results Summary Category Items Found Journal Articles 5686 Books / Periodicals / Audio Visual 161 Consumer Health 7 Meeting Abstracts 108 Other Collections 4 Total 5966

HSTAT36 HSTAT is a free, Web-based resource that provides access to full-text documents used in healthcare decision-making.37 HSTAT's audience includes healthcare providers, health service researchers, policy makers, insurance companies, consumers, and the information professionals who serve these groups. HSTAT provides access to a wide variety of publications, including clinical practice guidelines, quick-reference guides for clinicians, consumer health brochures, evidence reports and technology assessments from the Agency for Healthcare Research and Quality (AHRQ), as well as AHRQ's Put Prevention Into Practice.38 Simply search by “heroin dependence” (or synonyms) at the following Web site: http://text.nlm.nih.gov.

Adapted from HSTAT: http://www.nlm.nih.gov/pubs/factsheets/hstat.html. The HSTAT URL is http://hstat.nlm.nih.gov/. 38 Other important documents in HSTAT include: the National Institutes of Health (NIH) Consensus Conference Reports and Technology Assessment Reports; the HIV/AIDS Treatment Information Service (ATIS) resource documents; the Substance Abuse and Mental Health Services Administration's Center for Substance Abuse Treatment (SAMHSA/CSAT) Treatment Improvement Protocols (TIP) and Center for Substance Abuse Prevention (SAMHSA/CSAP) Prevention Enhancement Protocols System (PEPS); the Public Health Service (PHS) Preventive Services Task Force's Guide to Clinical Preventive Services; the independent, nonfederal Task Force on Community Services Guide to Community Preventive Services; and the Health Technology Advisory Committee (HTAC) of the Minnesota Health Care Commission (MHCC) health technology evaluations. 36 37


Coffee Break: Tutorials for Biologists39 Some patients may wish to have access to a general healthcare site that takes a scientific view of the news and covers recent breakthroughs in biology that may one day assist physicians in developing treatments. To this end, we recommend “Coffee Break,” a collection of short reports on recent biological discoveries. Each report incorporates interactive tutorials that demonstrate how bioinformatics tools are used as a part of the research process. Currently, all Coffee Breaks are written by NCBI staff.40 Each report is about 400 words and is usually based on a discovery reported in one or more articles from recently published, peer-reviewed literature.41 This site has new articles every few weeks, so it can be considered an online magazine of sorts, and intended for general background information. You can access the Coffee Break Web site at the following hyperlink: http://www.ncbi.nlm.nih.gov/Coffeebreak/.

Other Commercial Databases In addition to resources maintained by official agencies, other databases exist that are commercial ventures addressing medical professionals. Here are a few examples that may interest you: ·

CliniWeb International: Index and table of contents to selected clinical information on the Internet; see http://www.ohsu.edu/cliniweb/.

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Image Engine: Multimedia electronic medical record system that integrates a wide range of digitized clinical images with textual data stored in the University of Pittsburgh Medical Center's MARS electronic medical record system; see the following Web site: http://www.cml.upmc.edu/cml/imageengine/imageEngine.html.

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Medical World Search: Searches full text from thousands of selected medical sites on the Internet; see http://www.mwsearch.com/.

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MedWeaver: Prototype system that allows users to search differential diagnoses for any list of signs and symptoms, to search medical

39 Adapted

from http://www.ncbi.nlm.nih.gov/Coffeebreak/Archive/FAQ.html. The figure that accompanies each article is frequently supplied by an expert external to NCBI, in which case the source of the figure is cited. The result is an interactive tutorial that tells a biological story. 41 After a brief introduction that sets the work described into a broader context, the report focuses on how a molecular understanding can provide explanations of observed biology and lead to therapies for diseases. Each vignette is accompanied by a figure and hypertext links that lead to a series of pages that interactively show how NCBI tools and resources are used in the research process.

40


literature, and to explore relevant Web http://www.med.virginia.edu/~wmd4n/medweaver.html. ·

sites;

see

Metaphrase: Middleware component intended for use by both caregivers and medical records personnel. It converts the informal language generally used by caregivers into terms from formal, controlled vocabularies; see the following Web site: http://www.lexical.com/Metaphrase.html.

The Genome Project and Heroin Dependence With all the discussion in the press about the Human Genome Project, it is only natural that physicians, researchers, and patients want to know about how human genes relate to heroin dependence. In the following section, we will discuss databases and references used by physicians and scientists who work in this area.

Online Mendelian Inheritance in Man (OMIM) The Online Mendelian Inheritance in Man (OMIM) database is a catalog of human genes and genetic disorders authored and edited by Dr. Victor A. McKusick and his colleagues at Johns Hopkins and elsewhere. OMIM was developed for the World Wide Web by the National Center for Biotechnology Information (NCBI).42 The database contains textual information, pictures, and reference information. It also contains copious links to NCBI's Entrez database of MEDLINE articles and sequence information. To search the database, go to http://www.ncbi.nlm.nih.gov/Omim/searchomim.html. Type “heroin dependence” (or synonyms) in the search box, and click “Submit Search.” If too many results appear, you can narrow the search by adding the word “clinical.” Each report will have additional links to related research and databases. By following these links, especially the link titled “Database Links,” you will be exposed to numerous specialized databases that are largely used by the scientific community. These databases are overly technical and seldom used by the general public, but offer an abundance of Adapted from http://www.ncbi.nlm.nih.gov/. Established in 1988 as a national resource for molecular biology information, NCBI creates public databases, conducts research in computational biology, develops software tools for analyzing genome data, and disseminates biomedical information--all for the better understanding of molecular processes affecting human health and disease.

42


information. The following is an example of the results you can obtain from the OMIM for heroin dependence: ·

Opioid Receptor, Delta-1 Web site: http://www.ncbi.nlm.nih.gov/htbinpost/Omim/dispmim?165195

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Opioid Receptor, Mu-1; Oprm1 Web site: http://www.ncbi.nlm.nih.gov/htbinpost/Omim/dispmim?600018

Genes and Disease (NCBI - Map) The Genes and Disease database is produced by the National Center for Biotechnology Information of the National Library of Medicine at the National Institutes of Health. This Web site categorizes each disorder by the system of the body associated with it. Go to http://www.ncbi.nlm.nih.gov/disease/, and browse the system pages to have a full view of important conditions linked to human genes. Since this site is regularly updated, you may wish to re-visit it from time to time. The following systems and associated disorders are addressed: ·

Metabolism: Food and energy. Examples: Adreno-leukodystrophy, Atherosclerosis, Best disease, Gaucher disease, Glucose galactose malabsorption, Gyrate atrophy, Juvenile onset diabetes, Obesity, Paroxysmal nocturnal hemoglobinuria, Phenylketonuria, Refsum disease, Tangier disease, Tay-Sachs disease. Web site: http://www.ncbi.nlm.nih.gov/disease/Metabolism.html

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Nervous System: Mind and body. Examples: Alzheimer disease, Amyotrophic lateral sclerosis, Angelman syndrome, Charcot-Marie-Tooth disease, epilepsy, essential tremor, Fragile X syndrome, Friedreich's ataxia, Huntington disease, NiemannPick disease, Parkinson disease, Prader-Willi syndrome, Rett syndrome, Spinocerebellar atrophy, Williams syndrome. Web site: http://www.ncbi.nlm.nih.gov/disease/Brain.html

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Signals: Cellular messages. Examples: Ataxia telangiectasia, Baldness, Cockayne syndrome, Glaucoma, SRY: sex determination, Tuberous sclerosis, Waardenburg syndrome, Werner syndrome. Web site: http://www.ncbi.nlm.nih.gov/disease/Signals.html

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Transporters: Pumps and channels. Examples: Cystic Fibrosis, deafness, diastrophic dysplasia, Hemophilia A, long-QT syndrome, Menkes syndrome, Pendred syndrome, polycystic


kidney disease, sickle cell anemia, Wilson's disease, Zellweger syndrome. Web site: http://www.ncbi.nlm.nih.gov/disease/Transporters.html

Entrez Entrez is a search and retrieval system that integrates several linked databases at the National Center for Biotechnology Information (NCBI). These databases include nucleotide sequences, protein sequences, macromolecular structures, whole genomes, and MEDLINE through PubMed. Entrez provides access to the following databases: ·

PubMed: Biomedical literature (PubMed), Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed

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Nucleotide Sequence Database (Genbank): Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=Nucleotide

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Protein Sequence Database: Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=Protein

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Structure: Three-dimensional macromolecular structures, Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=Structure

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Genome: Complete genome assemblies, Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=Genome

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PopSet: Population study data sets, Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=Popset

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OMIM: Online Mendelian Inheritance in Man, Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=OMIM

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Taxonomy: Organisms in GenBank, Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=Taxonomy

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Books: Online books, Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=books

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ProbeSet: Gene Expression Omnibus (GEO), Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=geo

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3D Domains: Domains from Entrez Structure, Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=geo

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NCBI's Protein Sequence Information Survey Results: Web site: http://www.ncbi.nlm.nih.gov/About/proteinsurvey/


To access the Entrez system at the National Center for Biotechnology Information, go to http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?CMD=search&DB=genom e, and then select the database that you would like to search. The databases available are listed in the drop box next to “Search.” In the box next to “for,” enter “heroin dependence” (or synonyms) and click “Go.” Jablonski's Multiple Congenital Anomaly/Mental Retardation (MCA/MR) Syndromes Database43 This online resource can be quite useful. It has been developed to facilitate the identification and differentiation of syndromic entities. Special attention is given to the type of information that is usually limited or completely omitted in existing reference sources due to space limitations of the printed form. At the following Web site you can also search across syndromes using an index: http://www.nlm.nih.gov/mesh/jablonski/syndrome_toc/toc_a.html. You can search by keywords at this Web site: http://www.nlm.nih.gov/mesh/jablonski/syndrome_db.html. The Genome Database44 Established at Johns Hopkins University in Baltimore, Maryland in 1990, the Genome Database (GDB) is the official central repository for genomic mapping data resulting from the Human Genome Initiative. In the spring of 1999, the Bioinformatics Supercomputing Centre (BiSC) at the Hospital for Sick Children in Toronto, Ontario assumed the management of GDB. The Human Genome Initiative is a worldwide research effort focusing on structural analysis of human DNA to determine the location and sequence of the estimated 100,000 human genes. In support of this project, GDB stores and curates data generated by researchers worldwide who are engaged in the mapping effort of the Human Genome Project (HGP). GDB's mission is to provide scientists with an encyclopedia of the human genome which is continually revised and updated to reflect the current state of scientific knowledge. Although GDB has historically focused on gene mapping, its

Adapted from the National Library of Medicine: http://www.nlm.nih.gov/mesh/jablonski/about_syndrome.html. 44 Adapted from the Genome Database: http://gdbwww.gdb.org/gdb/aboutGDB.html#mission. 43


focus will broaden as the Genome Project moves from mapping to sequence, and finally, to functional analysis. To access the GDB, simply go to the following hyperlink: http://www.gdb.org/. Search “All Biological Data” by “Keyword.” Type “heroin dependence” (or synonyms) into the search box, and review the results. If more than one word is used in the search box, then separate each one with the word “and” or “or” (using “or” might be useful when using synonyms). This database is extremely technical as it was created for specialists. The articles are the results which are the most accessible to nonprofessionals and often listed under the heading “Citations.” The contact names are also accessible to non-professionals.

Specialized References The following books are specialized references written for professionals interested in heroin dependence (sorted alphabetically by title, hyperlinks provide rankings, information, and reviews at Amazon.com): · American Psychiatric Press Textbook of Substance Abuse Treatment by Marc Galanter (Editor), Herbert D. Kleber (Editor); Hardcover - 595 pages, 2nd edition (May 15, 1999), American Psychiatric Press; ISBN: 0880488204; http://www.amazon.com/exec/obidos/ASIN/0880488204/icongroupinterna · Combining Medication and Psychosocial Treatments for Addictions: The BRENDA Approach by Joseph Volpicelli (Editor), et al; Hardcover 208 pages, 1st edition (February 15, 2001), Guilford Press; ISBN: 1572306181; http://www.amazon.com/exec/obidos/ASIN/1572306181/icongroupinterna · Drink, Drugs and Dependence: From Science to Clinical Practice by Woody Caan (Editor); Paperback - 272 pages (June 1, 2002), Routledge; ISBN: 0415279011; http://www.amazon.com/exec/obidos/ASIN/0415279011/icongroupinterna · Neurobiology of Addictions: Implications for Clinical Practice by Richard T. Spence (Editor), et al; Hardcover (February 2002); ISBN: 0789016664; http://www.amazon.com/exec/obidos/ASIN/0789016664/icongroupinterna · Solutions for the 'Treatment-Resistant' Addicted Client : Therapeutic Techniques for Engaging Challenging Clients by Nicholas A. Roes; Textbook Binding (January 2002), Haworth Press; ISBN: 0789011204; http://www.amazon.com/exec/obidos/ASIN/0789011204/icongroupinterna


· Substance Abuse: A Guide for Health Professionals by American Academy of Pediatrics, et al; Paperback - 379 pages, 2nd edition (November 15, 2001), American Nurses Association; ISBN: 1581100728; http://www.amazon.com/exec/obidos/ASIN/1581100728/icongroupinterna

Vocabulary Builder Nicotine: An alkaloid derived from the tobacco plant that is responsible for smoking's psychoactive and addictive effects; is toxic at high doses but can be safe and effective as medicine at lower doses. [NIH]

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PART III. APPENDICES

ABOUT PART III Part III is a collection of appendices on general medical topics which may be of interest to patients with heroin dependence and related conditions.

Researching Your Medications 125

APPENDIX A. RESEARCHING YOUR MEDICATIONS Overview There are a number of sources available on new or existing medications which could be prescribed to patients with heroin dependence. While a number of hard copy or CD-Rom resources are available to patients and physicians for research purposes, a more flexible method is to use Internetbased databases. In this chapter, we will begin with a general overview of medications. We will then proceed to outline official recommendations on how you should view your medications. You may also want to research medications that you are currently taking for other conditions as they may interact with medications for heroin dependence. Research can give you information on the side effects, interactions, and limitations of prescription drugs used in the treatment of heroin dependence. Broadly speaking, there are two sources of information on approved medications: public sources and private sources. We will emphasize free-to-use public sources.

Your Medications: The Basics45 The Agency for Health Care Research and Quality has published extremely useful guidelines on how you can best participate in the medication aspects of heroin dependence. Taking medicines is not always as simple as swallowing a pill. It can involve many steps and decisions each day. The AHCRQ recommends that patients with heroin dependence take part in treatment decisions. Do not be afraid to ask questions and talk about your concerns. By taking a moment to ask questions early, you may avoid

45

This section is adapted from AHCRQ: http://www.ahcpr.gov/consumer/ncpiebro.htm.


problems later. Here are some points to cover each time a new medicine is prescribed: ·

Ask about all parts of your treatment, including diet changes, exercise, and medicines.

·

Ask about the risks and benefits of each medicine or other treatment you might receive.

·

Ask how often you or your doctor will check for side effects from a given medication.

Do not hesitate to ask what is important to you about your medicines. You may want a medicine with the fewest side effects, or the fewest doses to take each day. You may care most about cost, or how the medicine might affect how you live or work. Or, you may want the medicine your doctor believes will work the best. Telling your doctor will help him or her select the best treatment for you. Do not be afraid to “bother” your doctor with your concerns and questions about medications for heroin dependence. You can also talk to a nurse or a pharmacist. They can help you better understand your treatment plan. Feel free to bring a friend or family member with you when you visit your doctor. Talking over your options with someone you trust can help you make better choices, especially if you are not feeling well. Specifically, ask your doctor the following: ·

The name of the medicine and what it is supposed to do.

·

How and when to take the medicine, how much to take, and for how long.

·

What food, drinks, other medicines, or activities you should avoid while taking the medicine.

·

What side effects the medicine may have, and what to do if they occur.

·

If you can get a refill, and how often.

·

About any terms or directions you do not understand.

·

What to do if you miss a dose.

·

If there is written information you can take home (most pharmacies have information sheets on your prescription medicines; some even offer large-print or Spanish versions).

Do not forget to tell your doctor about all the medicines you are currently taking (not just those for heroin dependence). This includes prescription


medicines and the medicines that you buy over the counter. Then your doctor can avoid giving you a new medicine that may not work well with the medications you take now. When talking to your doctor, you may wish to prepare a list of medicines you currently take, the reason you take them, and how you take them. Be sure to include the following information for each: ·

Name of medicine

·

Reason taken

·

Dosage

·

Time(s) of day

Also include any over-the-counter medicines, such as: ·

Laxatives

·

Diet pills

·

Vitamins

·

Cold medicine

·

Aspirin or other pain, headache, or fever medicine

·

Cough medicine

·

Allergy relief medicine

·

Antacids

·

Sleeping pills

·

Others (include names)

Learning More about Your Medications Because of historical investments by various organizations and the emergence of the Internet, it has become rather simple to learn about the medications your doctor has recommended for heroin dependence. One such source is the United States Pharmacopeia. In 1820, eleven physicians met in Washington, D.C. to establish the first compendium of standard drugs for the United States. They called this compendium the “U.S. Pharmacopeia (USP).” Today, the USP is a non-profit organization consisting of 800 volunteer scientists, eleven elected officials, and 400 representatives of state associations and colleges of medicine and pharmacy. The USP is located in Rockville, Maryland, and its home page is located at www.usp.org. The USP currently provides standards for over 3,700 medications. The resulting USP


DIÒ Advice for the PatientÒ can be accessed through the National Library of Medicine of the National Institutes of Health. The database is partially derived from lists of federally approved medications in the Food and Drug Administration's (FDA) Drug Approvals database.46 While the FDA database is rather large and difficult to navigate, the Phamacopeia is both user-friendly and free to use. It covers more than 9,000 prescription and over-the-counter medications. To access this database, simply type the following hyperlink into your Web browser: http://www.nlm.nih.gov/medlineplus/druginformation.html. To view examples of a given medication (brand names, category, description, preparation, proper use, precautions, side effects, etc.), simply follow the hyperlinks indicated within the United States Pharmacopoeia (USP). It is important to read the disclaimer by the USP (http://www.nlm.nih.gov/medlineplus/drugdisclaimer.html) before using the information provided. Of course, we as editors cannot be certain as to what medications you are taking. Therefore, we have compiled a list of medications associated with the treatment of heroin dependence. Once again, due to space limitations, we only list a sample of medications and provide hyperlinks to ample documentation (e.g. typical dosage, side effects, drug-interaction risks, etc.). The following drugs have been mentioned in the Pharmacopeia and other sources as being potentially applicable to heroin dependence: Narcotic Analgesics for Pain Relief ·

Systemic - U.S. Brands: Astramorph PF; Buprenex; Cotanal-65; Darvon; Darvon-N; Demerol; Dilaudid; Dilaudid-5; Dilaudid-HP; Dolophine; Duramorph; Hydrostat IR; Kadian; Levo-Dromoran; M S Contin; Methadose; MS/L; MS/L Concentrate; MS/S; MSIR; Nubain; Numorphan; OMS Concentrate; http://www.nlm.nih.gov/medlineplus/druginfo/narcoticanalgesi csforpainrelie202390.html

Commercial Databases In addition to the medications listed in the USP above, a number of commercial sites are available by subscription to physicians and their Though cumbersome, the FDA database can be freely browsed at the following site: www.fda.gov/cder/da/da.htm.

46


institutions. You may be able to access these sources from your local medical library or your doctor's office.

Reuters Health Drug Database The Reuters Health Drug Database can be searched by keyword at the hyperlink: http://www.reutershealth.com/frame2/drug.html. The following medications are listed in the Reuters' database as associated with heroin dependence (including those with contraindications):47 ·

Guanfacine HCl http://www.reutershealth.com/atoz/html/Guanfacine_HCl.htm

·

Methadone HCl http://www.reutershealth.com/atoz/html/Methadone_HCl.htm

·

Pentazocine http://www.reutershealth.com/atoz/html/Pentazocine.htm

Mosby's GenRx Mosby's GenRx database (also available on CD-Rom and book format) covers 45,000 drug products including generics and international brands. It provides prescribing information, drug interactions, and patient information. Information can be obtained at the following hyperlink: http://www.genrx.com/Mosby/PhyGenRx/group.html. Physicians Desk Reference The Physicians Desk Reference database (also available in CD-Rom and book format) is a full-text drug database. The database is searchable by brand name, generic name or by indication. It features multiple drug interactions reports. Information can be obtained at the following hyperlink: http://physician.pdr.net/physician/templates/en/acl/psuser_t.htm.

Other Web Sites A number of additional Web sites discuss drug information. As an example, you may like to look at www.drugs.com which reproduces the information 47

Adapted from A to Z Drug Facts by Facts and Comparisons.


in the Pharmacopeia as well as commercial information. You may also want to consider the Web site of the Medical Letter, Inc. which allows users to download articles on various drugs and therapeutics for a nominal fee: http://www.medletter.com/.

Contraindications and Interactions (Hidden Dangers) Some of the medications mentioned in the previous discussions can be problematic for patients with heroin dependence--not because they are used in the treatment process, but because of contraindications, or side effects. Medications with contraindications are those that could react with drugs used to treat heroin dependence or potentially create deleterious side effects in patients with heroin dependence. You should ask your physician about any contraindications, especially as these might apply to other medications that you may be taking for common ailments. Drug-drug interactions occur when two or more drugs react with each other. This drug-drug interaction may cause you to experience an unexpected side effect. Drug interactions may make your medications less effective, cause unexpected side effects, or increase the action of a particular drug. Some drug interactions can even be harmful to you. Be sure to read the label every time you use a nonprescription or prescription drug, and take the time to learn about drug interactions. These precautions may be critical to your health. You can reduce the risk of potentially harmful drug interactions and side effects with a little bit of knowledge and common sense. Drug labels contain important information about ingredients, uses, warnings, and directions which you should take the time to read and understand. Labels also include warnings about possible drug interactions. Further, drug labels may change as new information becomes available. This is why it's especially important to read the label every time you use a medication. When your doctor prescribes a new drug, discuss all over-thecounter and prescription medications, dietary supplements, vitamins, botanicals, minerals and herbals you take as well as the foods you eat. Ask your pharmacist for the package insert for each prescription drug you take. The package insert provides more information about potential drug interactions.


A Final Warning At some point, you may hear of alternative medications from friends, relatives, or in the news media. Advertisements may suggest that certain alternative drugs can produce positive results for patients with heroin dependence. Exercise caution--some of these drugs may have fraudulent claims, and others may actually hurt you. The Food and Drug Administration (FDA) is the official U.S. agency charged with discovering which medications are likely to improve the health of patients with heroin dependence. The FDA warns patients to watch out for48: ·

Secret formulas (real scientists share what they know)

·

Amazing breakthroughs or miracle cures (real breakthroughs don't happen very often; when they do, real scientists do not call them amazing or miracles)

·

Quick, painless, or guaranteed cures

·

If it sounds too good to be true, it probably isn't true.

If you have any questions about any kind of medical treatment, the FDA may have an office near you. Look for their number in the blue pages of the phone book. You can also contact the FDA through its toll-free number, 1888-INFO-FDA (1-888-463-6332), or on the World Wide Web at www.fda.gov.

General References In addition to the resources provided earlier in this chapter, the following general references describe medications (sorted alphabetically by title; hyperlinks provide rankings, information and reviews at Amazon.com): ·

Complete Guide to Prescription and Nonprescription Drugs 2001 (Complete Guide to Prescription and Nonprescription Drugs, 2001) by H. Winter Griffith, Paperback 16th edition (2001), Medical Surveillance; ISBN: 0942447417; http://www.amazon.com/exec/obidos/ASIN/039952634X/icongroupinterna

·

The Essential Guide to Prescription Drugs, 2001 by James J. Rybacki, James W. Long; Paperback - 1274 pages (2001), Harper Resource; ISBN: 0060958162; http://www.amazon.com/exec/obidos/ASIN/0060958162/icongroupinterna

48

This section has been adapted from http://www.fda.gov/opacom/lowlit/medfraud.html.


·

Handbook of Commonly Prescribed Drugs by G. John Digregorio, Edward J. Barbieri; Paperback 16th edition (2001), Medical Surveillance; ISBN: 0942447417; http://www.amazon.com/exec/obidos/ASIN/0942447417/icongroupinterna

·

Johns Hopkins Complete Home Encyclopedia of Drugs 2nd ed. by Simeon Margolis (Ed.), Johns Hopkins; Hardcover - 835 pages (2000), Rebus; ISBN: 0929661583; http://www.amazon.com/exec/obidos/ASIN/0929661583/icongroupinterna

·

Medical Pocket Reference: Drugs 2002 by Springhouse Paperback 1st edition (2001), Lippincott Williams & Wilkins Publishers; ISBN: 1582550964; http://www.amazon.com/exec/obidos/ASIN/1582550964/icongroupinterna

·

PDR by Medical Economics Staff, Medical Economics Staff Hardcover 3506 pages 55th edition (2000), Medical Economics Company; ISBN: 1563633752; http://www.amazon.com/exec/obidos/ASIN/1563633752/icongroupinterna

·

Pharmacy Simplified: A Glossary of Terms by James Grogan; Paperback 432 pages, 1st edition (2001), Delmar Publishers; ISBN: 0766828581; http://www.amazon.com/exec/obidos/ASIN/0766828581/icongroupinterna

·

Physician Federal Desk Reference by Christine B. Fraizer; Paperback 2nd edition (2001), Medicode Inc; ISBN: 1563373971; http://www.amazon.com/exec/obidos/ASIN/1563373971/icongroupinterna

·

Physician's Desk Reference Supplements Paperback - 300 pages, 53 edition (1999), ISBN: 1563632950; http://www.amazon.com/exec/obidos/ASIN/1563632950/icongroupinterna

Vocabulary Builder The following vocabulary builder gives definitions of words used in this chapter that have not been defined in previous chapters: Analgesics: A group of medications that reduce pain. [NIH] Systemic: Pertaining to or affecting the body as a whole. [EU]

Researching Alternative Medicine 133

APPENDIX B. RESEARCHING ALTERNATIVE MEDICINE Overview Complementary and alternative medicine (CAM) is one of the most contentious aspects of modern medical practice. You may have heard of these treatments on the radio or on television. Maybe you have seen articles written about these treatments in magazines, newspapers, or books. Perhaps your friends or doctor have mentioned alternatives. In this chapter, we will begin by giving you a broad perspective on complementary and alternative therapies. Next, we will introduce you to official information sources on CAM relating to heroin dependence. Finally, at the conclusion of this chapter, we will provide a list of readings on heroin dependence from various authors. We will begin, however, with the National Center for Complementary and Alternative Medicine's (NCCAM) overview of complementary and alternative medicine.

What Is CAM?49 Complementary and alternative medicine (CAM) covers a broad range of healing philosophies, approaches, and therapies. Generally, it is defined as those treatments and healthcare practices which are not taught in medical schools, used in hospitals, or reimbursed by medical insurance companies. Many CAM therapies are termed “holistic,” which generally means that the healthcare practitioner considers the whole person, including physical, mental, emotional, and spiritual health. Some of these therapies are also known as “preventive,” which means that the practitioner educates and 49

Adapted from the NCCAM: http://nccam.nih.gov/nccam/fcp/faq/index.html#what-is.


treats the person to prevent health problems from arising, rather than treating symptoms after problems have occurred. People use CAM treatments and therapies in a variety of ways. Therapies are used alone (often referred to as alternative), in combination with other alternative therapies, or in addition to conventional treatment (sometimes referred to as complementary). Complementary and alternative medicine, or “integrative medicine,” includes a broad range of healing philosophies, approaches, and therapies. Some approaches are consistent with physiological principles of Western medicine, while others constitute healing systems with non-Western origins. While some therapies are far outside the realm of accepted Western medical theory and practice, others are becoming established in mainstream medicine. Complementary and alternative therapies are used in an effort to prevent illness, reduce stress, prevent or reduce side effects and symptoms, or control or cure disease. Some commonly used methods of complementary or alternative therapy include mind/body control interventions such as visualization and relaxation, manual healing including acupressure and massage, homeopathy, vitamins or herbal products, and acupuncture.

What Are the Domains of Alternative Medicine?50 The list of CAM practices changes continually. The reason being is that these new practices and therapies are often proved to be safe and effective, and therefore become generally accepted as “mainstream” healthcare practices. Today, CAM practices may be grouped within five major domains: (1) alternative medical systems, (2) mind-body interventions, (3) biologicallybased treatments, (4) manipulative and body-based methods, and (5) energy therapies. The individual systems and treatments comprising these categories are too numerous to list in this sourcebook. Thus, only limited examples are provided within each. Alternative Medical Systems Alternative medical systems involve complete systems of theory and practice that have evolved independent of, and often prior to, conventional biomedical approaches. Many are traditional systems of medicine that are

50

Adapted from the NCCAM: http://nccam.nih.gov/nccam/fcp/classify/index.html.


practiced by individual cultures throughout the world, including a number of venerable Asian approaches. Traditional oriental medicine emphasizes the balance or disturbances of qi (pronounced chi) or vital energy in health and disease, respectively. Traditional oriental medicine consists of a group of techniques and methods including acupuncture, herbal medicine, oriental massage, and qi gong (a form of energy therapy). Acupuncture involves stimulating specific anatomic points in the body for therapeutic purposes, usually by puncturing the skin with a thin needle. Ayurveda is India's traditional system of medicine. Ayurvedic medicine (meaning “science of life”) is a comprehensive system of medicine that places equal emphasis on body, mind, and spirit. Ayurveda strives to restore the innate harmony of the individual. Some of the primary Ayurvedic treatments include diet, exercise, meditation, herbs, massage, exposure to sunlight, and controlled breathing. Other traditional healing systems have been developed by the world’s indigenous populations. These populations include Native American, Aboriginal, African, Middle Eastern, Tibetan, and Central and South American cultures. Homeopathy and naturopathy are also examples of complete alternative medicine systems. Homeopathic medicine is an unconventional Western system that is based on the principle that “like cures like,” i.e., that the same substance that in large doses produces the symptoms of an illness, in very minute doses cures it. Homeopathic health practitioners believe that the more dilute the remedy, the greater its potency. Therefore, they use small doses of specially prepared plant extracts and minerals to stimulate the body's defense mechanisms and healing processes in order to treat illness. Naturopathic medicine is based on the theory that disease is a manifestation of alterations in the processes by which the body naturally heals itself and emphasizes health restoration rather than disease treatment. Naturopathic physicians employ an array of healing practices, including the following: diet and clinical nutrition, homeopathy, acupuncture, herbal medicine, hydrotherapy (the use of water in a range of temperatures and methods of applications), spinal and soft-tissue manipulation, physical therapies (such as those involving electrical currents, ultrasound, and light), therapeutic counseling, and pharmacology.


Mind-Body Interventions Mind-body interventions employ a variety of techniques designed to facilitate the mind's capacity to affect bodily function and symptoms. Only a select group of mind-body interventions having well-documented theoretical foundations are considered CAM. For example, patient education and cognitive-behavioral approaches are now considered “mainstream.” On the other hand, complementary and alternative medicine includes meditation, certain uses of hypnosis, dance, music, and art therapy, as well as prayer and mental healing.

Biological-Based Therapies This category of CAM includes natural and biological-based practices, interventions, and products, many of which overlap with conventional medicine's use of dietary supplements. This category includes herbal, special dietary, orthomolecular, and individual biological therapies. Herbal therapy employs an individual herb or a mixture of herbs for healing purposes. An herb is a plant or plant part that produces and contains chemical substances that act upon the body. Special diet therapies, such as those proposed by Drs. Atkins, Ornish, Pritikin, and Weil, are believed to prevent and/or control illness as well as promote health. Orthomolecular therapies aim to treat disease with varying concentrations of chemicals such as magnesium, melatonin, and mega-doses of vitamins. Biological therapies include, for example, the use of laetrile and shark cartilage to treat cancer and the use of bee pollen to treat autoimmune and inflammatory diseases.

Manipulative and Body-Based Methods This category includes methods that are based on manipulation and/or movement of the body. For example, chiropractors focus on the relationship between structure and function, primarily pertaining to the spine, and how that relationship affects the preservation and restoration of health. Chiropractors use manipulative therapy as an integral treatment tool. In contrast, osteopaths place particular emphasis on the musculoskeletal system and practice osteopathic manipulation. Osteopaths believe that all of the body's systems work together and that disturbances in one system may have an impact upon function elsewhere in the body. Massage therapists manipulate the soft tissues of the body to normalize those tissues.


Energy Therapies Energy therapies focus on energy fields originating within the body (biofields) or those from other sources (electromagnetic fields). Biofield therapies are intended to affect energy fields (the existence of which is not yet experimentally proven) that surround and penetrate the human body. Some forms of energy therapy manipulate biofields by applying pressure and/or manipulating the body by placing the hands in or through these fields. Examples include Qi gong, Reiki and Therapeutic Touch. Qi gong is a component of traditional oriental medicine that combines movement, meditation, and regulation of breathing to enhance the flow of vital energy (qi) in the body, improve blood circulation, and enhance immune function. Reiki, the Japanese word representing Universal Life Energy, is based on the belief that, by channeling spiritual energy through the practitioner, the spirit is healed and, in turn, heals the physical body. Therapeutic Touch is derived from the ancient technique of “laying-on of hands.” It is based on the premises that the therapist’s healing force affects the patient's recovery and that healing is promoted when the body's energies are in balance. By passing their hands over the patient, these healers identify energy imbalances. Bioelectromagnetic-based therapies involve the unconventional use of electromagnetic fields to treat illnesses or manage pain. These therapies are often used to treat asthma, cancer, and migraine headaches. Types of electromagnetic fields which are manipulated in these therapies include pulsed fields, magnetic fields, and alternating current or direct current fields.

Can Alternatives Affect My Treatment? A critical issue in pursuing complementary alternatives mentioned thus far is the risk that these might have undesirable interactions with your medical treatment. It becomes all the more important to speak with your doctor who can offer advice on the use of alternatives. Official sources confirm this view. Though written for women, we find that the National Women’s Health Information Center’s advice on pursuing alternative medicine is appropriate for patients of both genders and all ages.51

51

Adapted from http://www.4woman.gov/faq/alternative.htm.


Is It Okay to Want Both Traditional and Alternative or Complementary Medicine? Should you wish to explore non-traditional types of treatment, be sure to discuss all issues concerning treatments and therapies with your healthcare provider, whether a physician or practitioner of complementary and alternative medicine. Competent healthcare management requires knowledge of both conventional and alternative therapies you are taking for the practitioner to have a complete picture of your treatment plan. The decision to use complementary and alternative treatments is an important one. Consider before selecting an alternative therapy, the safety and effectiveness of the therapy or treatment, the expertise and qualifications of the healthcare practitioner, and the quality of delivery. These topics should be considered when selecting any practitioner or therapy.

Finding CAM References on Heroin Dependence Having read the previous discussion, you may be wondering which complementary or alternative treatments might be appropriate for heroin dependence. For the remainder of this chapter, we will direct you to a number of official sources which can assist you in researching studies and publications. Some of these articles are rather technical, so some patience may be required.

National Center for Complementary and Alternative Medicine The National Center for Complementary and Alternative Medicine (NCCAM) of the National Institutes of Health (http://nccam.nih.gov) has created a link to the National Library of Medicine's databases to allow patients to search for articles that specifically relate to heroin dependence and complementary medicine. To search the database, go to the following Web site: www.nlm.nih.gov/nccam/camonpubmed.html. Select “CAM on PubMed.” Enter “heroin dependence” (or synonyms) into the search box. Click “Go.” The following references provide information on particular aspects of complementary and alternative medicine (CAM) that are related to heroin dependence: ·

A cognitive behavioral analysis of relaxation training in drug abusers. Author(s): Chaney EF, Roszell DK.


Source: Drug and Alcohol Dependence. 1983 October; 12(2): 201-7. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=6360608&dopt=Abstract ·

A free clinic approach to drug abuse. Author(s): Gay GR, Smith DE. Source: Preventive Medicine. 1973 December; 2(4): 543-53. No Abstract Available. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=4778462&dopt=Abstract

·

A multiple baseline analysis of treatment for heroin addiction. Author(s): Epstein LH, Parker FC, Jenkins CC. Source: Addictive Behaviors. 1976; 1(4): 327-30. No Abstract Available. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=998363&dopt=Abstract

·

A primer on heroin. Author(s): Kaplan J. Source: Stanford Law Rev. 1975 February; 27(3): 801-26. No Abstract Available. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=800295&dopt=Abstract

·

A randomized double-blind study of neuroelectric therapy in opiate and cocaine detoxification. Author(s): Gariti P, Auriacombe M, Incmikoski R, McLellan AT, Patterson L, Dhopesh V, Mezochow J, Patterson M, O'Brien C. Source: Journal of Substance Abuse. 1992; 4(3): 299-308. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=1458046&dopt=Abstract

·

Acupuncture heroin detoxification: a single-blind clinical trial. Author(s): Washburn AM, Fullilove RE, Fullilove MT, Keenan PA, McGee B, Morris KA, Sorensen JL, Clark WW. Source: Journal of Substance Abuse Treatment. 1993 July-August; 10(4): 345-51. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=8411294&dopt=Abstract

·

Acupuncture in heroin addicts; changes in Met-enkephalin and betaendorphin in blood and cerebrospinal fluid.


Author(s): Clement-Jones V, McLoughlin L, Lowry PJ, Besser GM, Rees LH, Wen HL. Source: Lancet. 1979 August 25; 2(8139): 380-3. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=89447&dopt=Abstract ·

Acupuncture in heroin withdrawal. Author(s): Sainsbury MJ. Source: Med J Aust. 1974 July 20; 2(3): 102-5. No Abstract Available. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=4547132&dopt=Abstract

·

Acupuncture in narcotic withdrawal: a preliminary report on biochemical changes in the blood and urine of heroin addicts. Author(s): Wen HL, Ng YH, Ho WK, Fung KP, Wong HK, Ma L, Wong HC. Source: Bull Narc. 1978 April-June; 30(2): 31-9. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=216444&dopt=Abstract

·

Adolescent heroin use: a review. Author(s): Schwartz RH. Source: Pediatrics. 1998 December; 102(6): 1461-6. Review. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=9832585&dopt=Abstract

·

Autonomic functions and audiovisual reaction time in heroin addicts. Author(s): Kapoor R, Singh SH, Gandhi A. Source: Indian J Physiol Pharmacol. 1993 July; 37(3): 209-12. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=8276497&dopt=Abstract

·

Behavior-associated changes in blood pressure during heroin selfadministration. Author(s): Kiyatkin EA, Stein EA. Source: Pharmacology, Biochemistry, and Behavior. 1993 November; 46(3): 561-7. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=8278433&dopt=Abstract


·

Effects of acupuncture and an agonist of opiate receptors on heroin dependent patients. Author(s): Timofeev MF. Source: Am J Chin Med. 1999; 27(2): 143-8. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=10467448&dopt=Abstract

·

Evaluation of neoalleviase (NA-1700) in heroin detoxification: preliminary report on toxicity and efficacy including prophylactic measure in mice and clinical study. Author(s): Sang JB, Snow HD, Patin TL. Source: Int J Addict. 1980 August; 15(6): 883-7. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=7007259&dopt=Abstract

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Fast detoxification of heroin addicts by acupuncture and electrical stimulation (AES) in combination with naloxone. Author(s): Wen HL. Source: Comp Med East West. 1977 Fall-Winter; 5(3-4): 257-63. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=610976&dopt=Abstract

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Heroin detoxification with acupuncture and electrical stimulation. Author(s): Severson L, Markoff RA, Chun-Hoon A. Source: Int J Addict. 1977 October; 12(7): 911-22. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=591145&dopt=Abstract

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Immunoassayable beta-endorphin level in the plasma and CSF of heroin addicted and normal subjects before and after electroacupuncture. Author(s): Wen HL, Ho WK, Ling N, Mehal ZD, Ng YH. Source: Am J Chin Med. 1980 Spring-Summer; 8(1-2): 154-9. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=6967253&dopt=Abstract

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Impaired ACTH and beta-endorphin response to sauna-induced hyperthermia in heroin addicts. Author(s): Vescovi PP, Pedrazzoni M, Gerra G, Pioli G, Maninetti L, Michelini M, Passeri M.


Source: Acta Endocrinol (Copenh). 1989 October; 121(4): 484-8. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=2552728&dopt=Abstract ·

Impaired prolactin response to hyperthermia in heroin addicts. Author(s): Vescovi PP, Pedrazzoni M, Maninetti L, Pioli G, Gerra G, Passeri M. Source: Acta Endocrinol (Copenh). 1990 December; 123(6): 619-21. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=2126655&dopt=Abstract

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Juvenile drug addiction: a typology of heroin addicts and their families. Author(s): Cancrini L, Cingolani S, Compagnoni F, Costantini D, Mazzoni S. Source: Family Process. 1988 September; 27(3): 261-71. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=3224697&dopt=Abstract

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Letter: Acupuncture and heroin withdrawal. Author(s): Low SA. Source: Med J Aust. 1974 August 31; 2(9): 341. No Abstract Available. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=4419815&dopt=Abstract

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Letter: Heroin withdrawal using ear acupuncture. Author(s): Sainsbury MJ. Source: Med J Aust. 1974 June 1; 1(22): 899. No Abstract Available. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=4852807&dopt=Abstract

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Outpatient heroin detoxification with acupuncture and staplepuncture. Author(s): Tennant FS Jr. Source: The Western Journal of Medicine. 1976 September; 125(3): 191-4. No Abstract Available. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=1086037&dopt=Abstract

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Patients intoxicated with heroin or heroin mixtures: how long should they be monitored? Author(s): Osterwalder JJ.


Source: European Journal of Emergency Medicine : Official Journal of the European Society for Emergency Medicine. 1995 June; 2(2): 97-101. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=9422191&dopt=Abstract ·

Personality tailored covert sensitization of heroin abuse. Author(s): Snowden LR. Source: Addictive Behaviors. 1978; 3(1): 43-9. No Abstract Available. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=350013&dopt=Abstract

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Prenatal heroin exposure. Effects on development, acoustic startle response, and locomotion in weanling rats. Author(s): Zhu JH, Stadlin A. Source: Neurotoxicology and Teratology. 2000 March-April; 22(2): 193203. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=10758348&dopt=Abstract

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Short-term effects of heroin in man. Is EEG related to behavior? Author(s): Volavka J, Levine R, Feldstein S, Fink M. Source: Archives of General Psychiatry. 1974 May; 30(5): 677-81. No Abstract Available. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=4824201&dopt=Abstract

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Therapeutic effect of abstinence capsule on withdrawal symptoms of heroin addicts. Author(s): Yang X, Mao C, Jing F, Zhu G, Yang J, Liu G, Fang Z, Li Y, Cao X. Source: J Tradit Chin Med. 1999 December; 19(4): 243-9. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=10921125&dopt=Abstract

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Transcendental meditation as an alternative to heroin abuse in servicemen. Author(s): Anderson DJ. Source: The American Journal of Psychiatry. 1977 November; 134(11): 1308-9. No Abstract Available. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=333955&dopt=Abstract


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Use of qigong therapy in the detoxification of heroin addicts. Author(s): Li M, Chen K, Mo Z. Source: Alternative Therapies in Health and Medicine. 2002 JanuaryFebruary; 8(1): 50-4, 56-9. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=11795622&dopt=Abstract

Additional Web Resources A number of additional Web sites offer encyclopedic information covering CAM and related topics. The following is a representative sample: ·

Alternative Medicine Foundation, Inc.: http://www.herbmed.org/

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Chinese Medicine: http://www.newcenturynutrition.com/

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drkoop.comÒ: http://www.drkoop.com/InteractiveMedicine/IndexC.html

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Family Village: http://www.familyvillage.wisc.edu/med_altn.htm

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Google: http://directory.google.com/Top/Health/Alternative/

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Healthnotes: http://www.thedacare.org/healthnotes/

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Open Directory Project: http://dmoz.org/Health/Alternative/

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TPN.com: http://www.tnp.com/

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Yahoo.com: http://dir.yahoo.com/Health/Alternative_Medicine/

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WebMDÒHealth: http://my.webmd.com/drugs_and_herbs

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WellNet: http://www.wellnet.ca/herbsa-c.htm

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WholeHealthMD.com: http://www.wholehealthmd.com/reflib/0,1529,,00.html

The following is a specific Web list relating to heroin dependence; please note that any particular subject below may indicate either a therapeutic use, or a contraindication (potential danger), and does not reflect an official recommendation: ·

Related Conditions Parkinson's Disease


Source: Integrative Medicine Communications; www.onemedicine.com Hyperlink: http://www.drkoop.com/interactivemedicine/ConsConditions/Parkins onsDiseasecc.html Pulmonary Edema Source: Integrative Medicine Communications; www.onemedicine.com Hyperlink: http://www.drkoop.com/interactivemedicine/ConsConditions/Pulmo naryEdemacc.html

General References A good place to find general background information on CAM is the National Library of Medicine. It has prepared within the MEDLINEplus system an information topic page dedicated to complementary and alternative medicine. To access this page, go to the MEDLINEplus site at: www.nlm.nih.gov/medlineplus/alternativemedicine.html. This Web site provides a general overview of various topics and can lead to a number of general sources. The following additional references describe, in broad terms, alternative and complementary medicine (sorted alphabetically by title; hyperlinks provide rankings, information, and reviews at Amazon.com): · Clear Body, Clear Mind : The Effective Purification Program by L. Ron Hubbard; Paperback - 312 pages (June 2002), Bridge Publications; ISBN: 1573182249; http://www.amazon.com/exec/obidos/ASIN/1573182249/icongroupinterna · End Your Addiction Now: The Proven Nutritional Supplement Program That Can Set You Free by Charles Gant, Greg Lewis; Hardcover - 320 pages (January 2002), Warner Books; ISBN: 0446527238; http://www.amazon.com/exec/obidos/ASIN/0446527238/icongroupinterna · Reaching New Highs: Alternative Therapies for Drug Addicts by H. K. Heggenhougen; Hardcover (June 1997), Jason Aronson; ISBN: 0765700360; http://www.amazon.com/exec/obidos/ASIN/0765700360/icongroupinterna · The Tao of Sobriety : Helping You to Recover from Alcohol and Drug Addiction by David Gregson, et al; Paperback - 176 pages, 1st edition (January 2002), St. Martin's Press; ISBN: 0312242506; http://www.amazon.com/exec/obidos/ASIN/0312242506/icongroupinterna


For additional information on complementary and alternative medicine, ask your doctor or write to: National Institutes of Health National Center for Complementary and Alternative Medicine Clearinghouse P. O. Box 8218 Silver Spring, MD 20907-8218

Researching Nutrition 147

APPENDIX C. RESEARCHING NUTRITION Overview Since the time of Hippocrates, doctors have understood the importance of diet and nutrition to patients’ health and well-being. Since then, they have accumulated an impressive archive of studies and knowledge dedicated to this subject. Based on their experience, doctors and healthcare providers may recommend particular dietary supplements to patients with heroin dependence. Any dietary recommendation is based on a patient's age, body mass, gender, lifestyle, eating habits, food preferences, and health condition. It is therefore likely that different patients with heroin dependence may be given different recommendations. Some recommendations may be directly related to heroin dependence, while others may be more related to the patient's general health. These recommendations, themselves, may differ from what official sources recommend for the average person. In this chapter we will begin by briefly reviewing the essentials of diet and nutrition that will broadly frame more detailed discussions of heroin dependence. We will then show you how to find studies dedicated specifically to nutrition and heroin dependence.

Food and Nutrition: General Principles What Are Essential Foods? Food is generally viewed by official sources as consisting of six basic elements: (1) fluids, (2) carbohydrates, (3) protein, (4) fats, (5) vitamins, and (6) minerals. Consuming a combination of these elements is considered to be a healthy diet:


·

Fluids are essential to human life as 80-percent of the body is composed of water. Water is lost via urination, sweating, diarrhea, vomiting, diuretics (drugs that increase urination), caffeine, and physical exertion.

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Carbohydrates are the main source for human energy (thermoregulation) and the bulk of typical diets. They are mostly classified as being either simple or complex. Simple carbohydrates include sugars which are often consumed in the form of cookies, candies, or cakes. Complex carbohydrates consist of starches and dietary fibers. Starches are consumed in the form of pastas, breads, potatoes, rice, and other foods. Soluble fibers can be eaten in the form of certain vegetables, fruits, oats, and legumes. Insoluble fibers include brown rice, whole grains, certain fruits, wheat bran and legumes.

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Proteins are eaten to build and repair human tissues. Some foods that are high in protein are also high in fat and calories. Food sources for protein include nuts, meat, fish, cheese, and other dairy products.

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Fats are consumed for both energy and the absorption of certain vitamins. There are many types of fats, with many general publications recommending the intake of unsaturated fats or those low in cholesterol.

Vitamins and minerals are fundamental to human health, growth, and, in some cases, disease prevention. Most are consumed in your diet (exceptions being vitamins K and D which are produced by intestinal bacteria and sunlight on the skin, respectively). Each vitamin and mineral plays a different role in health. The following outlines essential vitamins: ·

Vitamin A is important to the health of your eyes, hair, bones, and skin; sources of vitamin A include foods such as eggs, carrots, and cantaloupe.

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Vitamin B1, also known as thiamine, is important for your nervous system and energy production; food sources for thiamine include meat, peas, fortified cereals, bread, and whole grains.

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Vitamin B2, also known as riboflavin, is important for your nervous system and muscles, but is also involved in the release of proteins from nutrients; food sources for riboflavin include dairy products, leafy vegetables, meat, and eggs.

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Vitamin B3, also known as niacin, is important for healthy skin and helps the body use energy; food sources for niacin include peas, peanuts, fish, and whole grains

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Vitamin B6, also known as pyridoxine, is important for the regulation of cells in the nervous system and is vital for blood formation; food sources for pyridoxine include bananas, whole grains, meat, and fish.


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Vitamin B12 is vital for a healthy nervous system and for the growth of red blood cells in bone marrow; food sources for vitamin B12 include yeast, milk, fish, eggs, and meat.

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Vitamin C allows the body's immune system to fight various diseases, strengthens body tissue, and improves the body's use of iron; food sources for vitamin C include a wide variety of fruits and vegetables.

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Vitamin D helps the body absorb calcium which strengthens bones and teeth; food sources for vitamin D include oily fish and dairy products.

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Vitamin E can help protect certain organs and tissues from various degenerative diseases; food sources for vitamin E include margarine, vegetables, eggs, and fish.

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Vitamin K is essential for bone formation and blood clotting; common food sources for vitamin K include leafy green vegetables.

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Folic Acid maintains healthy cells and blood and, when taken by a pregnant woman, can prevent her fetus from developing neural tube defects; food sources for folic acid include nuts, fortified breads, leafy green vegetables, and whole grains.

It should be noted that one can overdose on certain vitamins which become toxic if consumed in excess (e.g. vitamin A, D, E and K). Like vitamins, minerals are chemicals that are required by the body to remain in good health. Because the human body does not manufacture these chemicals internally, we obtain them from food and other dietary sources. The more important minerals include: ·

Calcium is needed for healthy bones, teeth, and muscles, but also helps the nervous system function; food sources for calcium include dry beans, peas, eggs, and dairy products.

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Chromium is helpful in regulating sugar levels in blood; food sources for chromium include egg yolks, raw sugar, cheese, nuts, beets, whole grains, and meat.

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Fluoride is used by the body to help prevent tooth decay and to reinforce bone strength; sources of fluoride include drinking water and certain brands of toothpaste.

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Iodine helps regulate the body's use of energy by synthesizing into the hormone thyroxine; food sources include leafy green vegetables, nuts, egg yolks, and red meat.


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Iron helps maintain muscles and the formation of red blood cells and certain proteins; food sources for iron include meat, dairy products, eggs, and leafy green vegetables.

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Magnesium is important for the production of DNA, as well as for healthy teeth, bones, muscles, and nerves; food sources for magnesium include dried fruit, dark green vegetables, nuts, and seafood.

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Phosphorous is used by the body to work with calcium to form bones and teeth; food sources for phosphorous include eggs, meat, cereals, and dairy products.

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Selenium primarily helps maintain normal heart and liver functions; food sources for selenium include wholegrain cereals, fish, meat, and dairy products.

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Zinc helps wounds heal, the formation of sperm, and encourage rapid growth and energy; food sources include dried beans, shellfish, eggs, and nuts.

The United States government periodically publishes recommended diets and consumption levels of the various elements of food. Again, your doctor may encourage deviations from the average official recommendation based on your specific condition. To learn more about basic dietary guidelines, visit the Web site: http://www.health.gov/dietaryguidelines/. Based on these guidelines, many foods are required to list the nutrition levels on the food’s packaging. Labeling Requirements are listed at the following site maintained by the Food and Drug Administration: http://www.cfsan.fda.gov/~dms/labcons.html. When interpreting these requirements, the government recommends that consumers become familiar with the following abbreviations before reading FDA literature:52 ·

DVs (Daily Values): A new dietary reference term that will appear on the food label. It is made up of two sets of references, DRVs and RDIs.

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DRVs (Daily Reference Values): A set of dietary references that applies to fat, saturated fat, cholesterol, carbohydrate, protein, fiber, sodium, and potassium.

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RDIs (Reference Daily Intakes): A set of dietary references based on the Recommended Dietary Allowances for essential vitamins and minerals and, in selected groups, protein. The name “RDI” replaces the term “U.S. RDA.”

52

Adapted from the FDA: http://www.fda.gov/fdac/special/foodlabel/dvs.html.


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RDAs (Recommended Dietary Allowances): A set of estimated nutrient allowances established by the National Academy of Sciences. It is updated periodically to reflect current scientific knowledge. What Are Dietary Supplements?53

Dietary supplements are widely available through many commercial sources, including health food stores, grocery stores, pharmacies, and by mail. Dietary supplements are provided in many forms including tablets, capsules, powders, gel-tabs, extracts, and liquids. Historically in the United States, the most prevalent type of dietary supplement was a multivitamin/mineral tablet or capsule that was available in pharmacies, either by prescription or “over the counter.” Supplements containing strictly herbal preparations were less widely available. Currently in the United States, a wide array of supplement products are available, including vitamin, mineral, other nutrients, and botanical supplements as well as ingredients and extracts of animal and plant origin. The Office of Dietary Supplements (ODS) of the National Institutes of Health is the official agency of the United States which has the expressed goal of acquiring “new knowledge to help prevent, detect, diagnose, and treat disease and disability, from the rarest genetic disorder to the common cold.”54 According to the ODS, dietary supplements can have an important impact on the prevention and management of disease and on the maintenance of health.55 The ODS notes that considerable research on the effects of dietary supplements has been conducted in Asia and Europe where the use of plant products, in particular, has a long tradition. However, the overwhelming majority of supplements have not been studied scientifically. To explore the role of dietary supplements in the improvement of health care, the ODS plans, organizes, and supports conferences, workshops, and symposia on scientific topics related to dietary supplements. The ODS often This discussion has been adapted from the NIH: http://ods.od.nih.gov/whatare/whatare.html. 54 Contact: The Office of Dietary Supplements, National Institutes of Health, Building 31, Room 1B29, 31 Center Drive, MSC 2086, Bethesda, Maryland 20892-2086, Tel: (301) 435-2920, Fax: (301) 480-1845, E-mail: [email protected]. 55 Adapted from http://ods.od.nih.gov/about/about.html. The Dietary Supplement Health and Education Act defines dietary supplements as “a product (other than tobacco) intended to supplement the diet that bears or contains one or more of the following dietary ingredients: a vitamin, mineral, amino acid, herb or other botanical; or a dietary substance for use to supplement the diet by increasing the total dietary intake; or a concentrate, metabolite, constituent, extract, or combination of any ingredient described above; and intended for ingestion in the form of a capsule, powder, softgel, or gelcap, and not represented as a conventional food or as a sole item of a meal or the diet.” 53


works in conjunction with other NIH Institutes and Centers, other government agencies, professional organizations, and public advocacy groups. To learn more about official information on dietary supplements, visit the ODS site at http://ods.od.nih.gov/whatare/whatare.html. Or contact: The Office of Dietary Supplements National Institutes of Health Building 31, Room 1B29 31 Center Drive, MSC 2086 Bethesda, Maryland 20892-2086 Tel: (301) 435-2920 Fax: (301) 480-1845 E-mail: [email protected]

Finding Studies on Heroin Dependence The NIH maintains an office dedicated to patient nutrition and diet. The National Institutes of Health’s Office of Dietary Supplements (ODS) offers a searchable bibliographic database called the IBIDS (International Bibliographic Information on Dietary Supplements). The IBIDS contains over 460,000 scientific citations and summaries about dietary supplements and nutrition as well as references to published international, scientific literature on dietary supplements such as vitamins, minerals, and botanicals.56 IBIDS is available to the public free of charge through the ODS Internet page: http://ods.od.nih.gov/databases/ibids.html. After entering the search area, you have three choices: (1) IBIDS Consumer Database, (2) Full IBIDS Database, or (3) Peer Reviewed Citations Only. We recommend that you start with the Consumer Database. While you may not find references for the topics that are of most interest to you, check back periodically as this database is frequently updated. More studies can be found by searching the Full IBIDS Database. Healthcare professionals and researchers generally use the third option, which lists peer-reviewed citations. In all cases, we suggest that you take advantage of the “Advanced Search” option that allows you to retrieve up to 100 fully explained Adapted from http://ods.od.nih.gov. IBIDS is produced by the Office of Dietary Supplements (ODS) at the National Institutes of Health to assist the public, healthcare providers, educators, and researchers in locating credible, scientific information on dietary supplements. IBIDS was developed and will be maintained through an interagency partnership with the Food and Nutrition Information Center of the National Agricultural Library, U.S. Department of Agriculture.

56


references in a comprehensive format. Type “heroin dependence” (or synonyms) into the search box. To narrow the search, you can also select the “Title” field. The following information is typical of that found when using the “Full IBIDS Database” when searching using “heroin dependence” (or a synonym): ·

A clinical trial of buprenorphine: I. Comparison with methadone in the detoxification of heroin addicts. II. Examination of its opioid blocking properties. Author(s): Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine. Source: Bickel, W K Johnson, R E Stitzer, M L Bigelow, G E Liebson, I A Jasinski, D R NIDA-Res-Monogr. 1987; 76182-8 1046-9516

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A novel paradigm to investigate regulation of drug intake in rats selfadministering cocaine or heroin intravenously. Author(s): Department of Psychiatry, University of Minnesota, Minneapolis 55455, USA. [email protected] Source: Lynch, W J LaBounty, L P Carroll, M E Exp-ClinPsychopharmacol. 1998 February; 6(1): 22-31 1064-1297

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A randomized trial of adding fluoxetine to a naltrexone treatment programme for heroin addicts. Author(s): Centro de Drogodependencias de Barakaldo, Vizcaya, Spain. Source: Landabaso, M A Iraurgi, I Jimenez Lerma, J M Sanz, J Fernadez de Corres, B Araluce, K Calle, R Gutierrez Fraile, M Addiction. 1998 May; 93(5): 739-44 0965-2140

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Antagonism of delta(2)-opioid receptors by naltrindole-5'isothiocyanate attenuates heroin self-administration but not antinociception in rats. Author(s): Department of Physiology and Pharmacology, Wake Forest University School of Medicine, Winston-Salem, NC 27157-1803, USA. [email protected] Source: Martin, T J Kim, S A Cannon, D G Sizemore, G M Bian, D Porreca, F Smith, J E J-Pharmacol-Exp-Ther. 2000 September; 294(3): 97582 0022-3565

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B vitamins status: effect of prolonged heroin addiction and methadone treatment. Author(s): Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.


Source: Prayurahong, B Migasena, P Pongpaew, P Vudhivai, N Busapathumrong, P J-Med-Assoc-Thai. 1991 March; 74(3): 131-5 01252208 ·

Buprenorphine treatment for concurrent heroin and cocaine dependence: phase I study. Author(s): Alcohol and Drug Abuse Research Center, Harvard Medical School, McLean Hospital, Belmont, MA 02178. Source: Mendelson, J H Mello, N K Teoh, S K Kuehnle, J Sintavanarong, P Dooley Coufos, K NIDA-Res-Monogr. 1991; 105196-202 1046-9516

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cAMP levels in monocytes of heroin addicts. Author(s): Departamento de Patologia General, Hospital Clinico Universitario, Salamanca Hispania. Source: Castrillon, J L Arellano, J L Palomo, J D Rodriguez, M M Lopez, A J Klin-Wochenschr. 1989 February 15; 67(4): 238-40 0023-2173

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Chronic naltrexone suppresses platelet aggregation induced by adrenaline and 5-hydroxytryptamine in former heroin addicts. Author(s): Department of Pharmacology, Faculty of Medicine, University of the Basque Country, Leioa. Source: Garcia Sevilla, J A Ulibarri, I Giralt, M T Areso, P Oliveros, R G Gutierrez, M J-Neural-Transm. 1988; 73(2): 157-60 0300-9564

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Controlled use of heroin in patients on methadone maintenance treatment. Author(s): Institute of Pharmacology, University of Siena, Italy. Source: Bianchi, E Maremmani, I Meloni, D Tagliamonte, A J-SubstAbuse-Treat. 1992 Fall; 9(4): 383-7 0740-5472

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Effect of chronic opioid administration on glycosylated haemoglobin levels in heroin addicts. Source: Sood, A Thakur, V Ahuja, M M Indian-J-Med-Res. 1989 February; 9051-4 0971-5916

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Effects of buprenorphine in heroin addicts. Author(s): Psychiatric Research Center, Ulleraker Hospital, Uppsala, Sweden. Source: Blom, Y Bondesson, U Gunne, L M Drug-Alcohol-Depend. 1987 September; 20(1): 1-7 0376-8716

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Focal myopathy induced by chronic heroin injection is reversible. Author(s): Department of Neurology, University Hospital Essen, Essen, Germany. [email protected] Source: Weber, M Diener, H C Voit, T Neuen Jacob, E Muscle-Nerve. 2000 February; 23(2): 274-7 0148-639X


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Follow-up after a six-month maintenance period on naltrexone versus placebo in heroin addicts. Author(s): Seccion de Toxicomanias, Hospital del Mar, Barcelona, Spain. Source: San, L Pomarol, G Peri, J M Olle, J M Cami, J Br-J-Addict. 1991 August; 86(8): 983-90 0952-0481

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Identification of 6-mono-acetylmorphine, as an indication of heroin abuse. Source: Kintz, P Tracqui, A Ludes, B Mangin, P Lugnier, A A Chaumont, A J Acta-Med-Leg-Soc-(Liege). 1989; 39(2): 464-9 0065-1397

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Immunoaffinity extraction of morphine, morphine-3-glucuronide and morphine-6-glucuronide from blood of heroin victims for simultaneous high-performance liquid chromatographic determination. Author(s): Institute of Legal Medicine, Westfalische WilhelmsUniversitat, Munster, Germany. Source: Beike, J Kohler, H Brinkmann, B Blaschke, G J-Chromatogr-BBiomed-Sci-Appl. 1999 April 16; 726(1-2): 111-9 1387-2273

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Increased mesolimbic GABA concentration blocks heroin selfadministration in the rat. Author(s): Department of Cellular Biology, Neurobiology and Anatomy, Medical College of Wisconsin, Milwaukee 53226, USA. Source: Xi, Z X Stein, E A J-Pharmacol-Exp-Ther. 2000 August; 294(2): 613-9 0022-3565

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Leptin attenuates acute food deprivation-induced relapse to heroin seeking. Author(s): Behavioral Neuroscience Branch, National Institute on Drug Abuse/Intramural Research Program, Baltimore, Maryland 21224, USA. Source: Shalev, U Yap, J Shaham, Y J-Neurosci. 2001 February 15; 21(4): RC129 1529-2401

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Naltrexone for heroin addiction: encouraging results from Italy. Author(s): Alcoholic and Drug Addicts Advisory Clinic, Local Health Unit N. 12, Conegliano, Italy. Source: Schifano, F Marra, R Int-J-Clin-Pharmacol-Ther-Toxicol. 1990 April; 28(4): 144-6 0174-4879

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Neonatal heroin withdrawal syndrome; evaluation of different pharmacological treatments. Author(s): Institute of Clinical and Experimental Oncology, University of Genova, Italy. Source: Pacifico, P Nardelli, E Pantarotto, M F Pharmacol-Res. 1989 NovDecember; 21 Suppl 163-4 1043-6618

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Preventing heroin overdose. Author(s): Royal Free and University College Medical School.


Source: Phillips, P Johnson, F Nurs-Stand. 2000 March 1-7; 14(24): 31 0029-6570

Federal Resources on Nutrition In addition to the IBIDS, the United States Department of Health and Human Services (HHS) and the United States Department of Agriculture (USDA) provide many sources of information on general nutrition and health. Recommended resources include: ·

healthfinder®, HHS's gateway to health information, including diet and nutrition: http://www.healthfinder.gov/scripts/SearchContext.asp?topic=238&pag e=0

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The United States Department of Agriculture's Web site dedicated to nutrition information: www.nutrition.gov

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The Food and Drug Administration's Web site for federal food safety information: www.foodsafety.gov

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The National Action Plan on Overweight and Obesity sponsored by the United States Surgeon General: http://www.surgeongeneral.gov/topics/obesity/

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The Center for Food Safety and Applied Nutrition has an Internet site sponsored by the Food and Drug Administration and the Department of Health and Human Services: http://vm.cfsan.fda.gov/

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Center for Nutrition Policy and Promotion sponsored by the United States Department of Agriculture: http://www.usda.gov/cnpp/

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Food and Nutrition Information Center, National Agricultural Library sponsored by the United States Department of Agriculture: http://www.nal.usda.gov/fnic/

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Food and Nutrition Service sponsored by the United States Department of Agriculture: http://www.fns.usda.gov/fns/

Additional Web Resources A number of additional Web sites offer encyclopedic information covering food and nutrition. The following is a representative sample: ·



·

Family Village: http://www.familyvillage.wisc.edu/med_nutrition.html

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Google: http://directory.google.com/Top/Health/Nutrition/

·

Healthnotes: http://www.thedacare.org/healthnotes/

·

Open Directory Project: http://dmoz.org/Health/Nutrition/

·

Yahoo.com: http://dir.yahoo.com/Health/Nutrition/

·

WebMDÒHealth: http://my.webmd.com/nutrition

·

WholeHealthMD.com: http://www.wholehealthmd.com/reflib/0,1529,,00.html

Vocabulary Builder The following vocabulary builder defines words used in the references in this chapter that have not been defined in previous chapters: Carbohydrate: An aldehyde or ketone derivative of a polyhydric alcohol, particularly of the pentahydric and hexahydric alcohols. They are so named because the hydrogen and oxygen are usually in the proportion to form water, (CH2O)n. The most important carbohydrates are the starches, sugars, celluloses, and gums. They are classified into mono-, di-, tri-, poly- and heterosaccharides. [EU] Cholesterol: The principal sterol of all higher animals, distributed in body tissues, especially the brain and spinal cord, and in animal fats and oils. [NIH] Degenerative: Undergoing degeneration : tending to degenerate; having the character of or involving degeneration; causing or tending to cause degeneration. [EU] Deprivation: Loss or absence of parts, organs, powers, or things that are needed. [EU] Extraction: The process or act of pulling or drawing out. [EU] Fluoxetine: The first highly specific serotonin uptake inhibitor. It is used as an antidepressant and often has a more acceptable side-effects profile than traditional antidepressants. [NIH] GABA: The most common inhibitory neurotransmitter in the central nervous system. [NIH] Hormone: A chemical substance formed in glands in the body and carried in the blood to organs and tissues, where it influences function, structure, and behavior. [NIH] Iodine: A nonmetallic element of the halogen group that is represented by


the atomic symbol I, atomic number 53, and atomic weight of 126.90. It is a nutritionally essential element, especially important in thyroid hormone synthesis. In solution, it has anti-infective properties and is used topically. [NIH]

Leptin: A 16-kD peptide hormone secreted from white adipocytes and implicated in the regulation of food intake and energy balance. Leptin provides the key afferent signal from fat cells in the feedback system that controls body fat stores. [NIH] Monocytes: Large, phagocytic mononuclear leukocytes produced in the vertebrate bone marrow and released into the blood; contain a large, oval or somewhat indented nucleus surrounded by voluminous cytoplasm and numerous organelles. [NIH] Myopathy: Any disease of a muscle. [EU] Neonatal: Pertaining to the first four weeks after birth. [EU] Neural: 1. pertaining to a nerve or to the nerves. 2. situated in the region of the spinal axis, as the neutral arch. [EU] Neurology: A medical specialty concerned with the study of the structures, functions, and diseases of the nervous system. [NIH] Niacin: Water-soluble vitamin of the B complex occurring in various animal and plant tissues. Required by the body for the formation of coenzymes NAD and NADP. Has pellagra-curative, vasodilating, and antilipemic properties. [NIH] Potassium: An element that is in the alkali group of metals. It has an atomic symbol K, atomic number 19, and atomic weight 39.10. It is the chief cation in the intracellular fluid of muscle and other cells. Potassium ion is a strong electrolyte and it plays a significant role in the regulation of fluid volume and maintenance of the water-electrolyte balance. [NIH] Riboflavin: Nutritional factor found in milk, eggs, malted barley, liver, kidney, heart, and leafy vegetables. The richest natural source is yeast. It occurs in the free form only in the retina of the eye, in whey, and in urine; its principal forms in tissues and cells are as FMN and FAD. [NIH] Selenium: An element with the atomic symbol Se, atomic number 34, and atomic weight 78.96. It is an essential micronutrient for mammals and other animals but is toxic in large amounts. Selenium protects intracellular structures against oxidative damage. It is an essential component of glutathione peroxidase. [NIH] Thermoregulation: Heat regulation. [EU] Thyroxine: An amino acid of the thyroid gland which exerts a stimulating effect on thyroid metabolism. [NIH] Toxicomania: Addiction to a drug (as opium or cocaine). [EU]

Finding Medical Libraries 159

APPENDIX D. FINDING MEDICAL LIBRARIES Overview At a medical library you can find medical texts and reference books, consumer health publications, specialty newspapers and magazines, as well as medical journals. In this Appendix, we show you how to quickly find a medical library in your area.

Preparation Before going to the library, highlight the references mentioned in this sourcebook that you find interesting. Focus on those items that are not available via the Internet, and ask the reference librarian for help with your search. He or she may know of additional resources that could be helpful to you. Most importantly, your local public library and medical libraries have Interlibrary Loan programs with the National Library of Medicine (NLM), one of the largest medical collections in the world. According to the NLM, most of the literature in the general and historical collections of the National Library of Medicine is available on interlibrary loan to any library. NLM's interlibrary loan services are only available to libraries. If you would like to access NLM medical literature, then visit a library in your area that can request the publications for you.57

57

Adapted from the NLM: http://www.nlm.nih.gov/psd/cas/interlibrary.html.


Finding a Local Medical Library The quickest method to locate medical libraries is to use the Internet-based directory published by the National Network of Libraries of Medicine (NN/LM). This network includes 4626 members and affiliates that provide many services to librarians, health professionals, and the public. To find a library in your area, simply visit http://nnlm.gov/members/adv.html or call 1-800-338-7657.

Medical Libraries Open to the Public In addition to the NN/LM, the National Library of Medicine (NLM) lists a number of libraries that are generally open to the public and have reference facilities. The following is the NLM’s list plus hyperlinks to each library Web site. These Web pages can provide information on hours of operation and other restrictions. The list below is a small sample of libraries recommended by the National Library of Medicine (sorted alphabetically by name of the U.S. state or Canadian province where the library is located):58 ·

Alabama: Health InfoNet of Jefferson County (Jefferson County Library Cooperative, Lister Hill Library of the Health Sciences), http://www.uab.edu/infonet/

·

Alabama: Richard M. Scrushy Library (American Sports Medicine Institute), http://www.asmi.org/LIBRARY.HTM

·

Arizona: Samaritan Regional Medical Center: The Learning Center (Samaritan Health System, Phoenix, Arizona), http://www.samaritan.edu/library/bannerlibs.htm

·

California: Kris Kelly Health Information Center (St. Joseph Health System), http://www.humboldt1.com/~kkhic/index.html

·

California: Community Health Library of Los Gatos (Community Health Library of Los Gatos), http://www.healthlib.org/orgresources.html

·

California: Consumer Health Program and Services (CHIPS) (County of Los Angeles Public Library, Los Angeles County Harbor-UCLA Medical Center Library) - Carson, CA, http://www.colapublib.org/services/chips.html

·

California: Gateway Health Library (Sutter Gould Medical Foundation)

·

California: Health Library (Stanford University Medical Center), http://www-med.stanford.edu/healthlibrary/

58

Abstracted from http://www.nlm.nih.gov/medlineplus/libraries.html.


·

California: Patient Education Resource Center - Health Information and Resources (University of California, San Francisco), http://sfghdean.ucsf.edu/barnett/PERC/default.asp

·

California: Redwood Health Library (Petaluma Health Care District), http://www.phcd.org/rdwdlib.html

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California: San José PlaneTree Health Library, http://planetreesanjose.org/

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California: Sutter Resource Library (Sutter Hospitals Foundation), http://go.sutterhealth.org/comm/resc-library/sac-resources.html

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California: University of California, Davis. Health Sciences Libraries

·

California: ValleyCare Health Library & Ryan Comer Cancer Resource Center (ValleyCare Health System), http://www.valleycare.com/library.html

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California: Washington Community Health Resource Library (Washington Community Health Resource Library), http://www.healthlibrary.org/

·

Colorado: William V. Gervasini Memorial Library (Exempla Healthcare), http://www.exempla.org/conslib.htm

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Connecticut: Hartford Hospital Health Science Libraries (Hartford Hospital), http://www.harthosp.org/library/

·

Connecticut: Healthnet: Connecticut Consumer Health Information Center (University of Connecticut Health Center, Lyman Maynard Stowe Library), http://library.uchc.edu/departm/hnet/

·

Connecticut: Waterbury Hospital Health Center Library (Waterbury Hospital), http://www.waterburyhospital.com/library/consumer.shtml

·

Delaware: Consumer Health Library (Christiana Care Health System, Eugene du Pont Preventive Medicine & Rehabilitation Institute), http://www.christianacare.org/health_guide/health_guide_pmri_health _info.cfm

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Delaware: Lewis B. Flinn Library (Delaware Academy of Medicine), http://www.delamed.org/chls.html

·

Georgia: Family Resource Library (Medical College of Georgia), http://cmc.mcg.edu/kids_families/fam_resources/fam_res_lib/frl.htm

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Georgia: Health Resource Center (Medical Center of Central Georgia), http://www.mccg.org/hrc/hrchome.asp

·

Hawaii: Hawaii Medical Library: Consumer Health Information Service (Hawaii Medical Library), http://hml.org/CHIS/


·

Idaho: DeArmond Consumer Health Library (Kootenai Medical Center), http://www.nicon.org/DeArmond/index.htm

·

Illinois: Health Learning Center of Northwestern Memorial Hospital (Northwestern Memorial Hospital, Health Learning Center), http://www.nmh.org/health_info/hlc.html

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Illinois: Medical Library (OSF Saint Francis Medical Center), http://www.osfsaintfrancis.org/general/library/

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Kentucky: Medical Library - Services for Patients, Families, Students & the Public (Central Baptist Hospital), http://www.centralbap.com/education/community/library.htm

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Kentucky: University of Kentucky - Health Information Library (University of Kentucky, Chandler Medical Center, Health Information Library), http://www.mc.uky.edu/PatientEd/

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Louisiana: Alton Ochsner Medical Foundation Library (Alton Ochsner Medical Foundation), http://www.ochsner.org/library/

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Louisiana: Louisiana State University Health Sciences Center Medical Library-Shreveport, http://lib-sh.lsuhsc.edu/

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Maine: Franklin Memorial Hospital Medical Library (Franklin Memorial Hospital), http://www.fchn.org/fmh/lib.htm

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Maine: Gerrish-True Health Sciences Library (Central Maine Medical Center), http://www.cmmc.org/library/library.html

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Maine: Hadley Parrot Health Science Library (Eastern Maine Healthcare), http://www.emh.org/hll/hpl/guide.htm

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Maine: Maine Medical Center Library (Maine Medical Center), http://www.mmc.org/library/

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Maine: Parkview Hospital, http://www.parkviewhospital.org/communit.htm#Library

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Maine: Southern Maine Medical Center Health Sciences Library (Southern Maine Medical Center), http://www.smmc.org/services/service.php3?choice=10

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Maine: Stephens Memorial Hospital Health Information Library (Western Maine Health), http://www.wmhcc.com/hil_frame.html

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Manitoba, Canada: Consumer & Patient Health Information Service (University of Manitoba Libraries), http://www.umanitoba.ca/libraries/units/health/reference/chis.html

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Manitoba, Canada: J.W. Crane Memorial Library (Deer Lodge Centre), http://www.deerlodge.mb.ca/library/libraryservices.shtml


·

Maryland: Health Information Center at the Wheaton Regional Library (Montgomery County, Md., Dept. of Public Libraries, Wheaton Regional Library), http://www.mont.lib.md.us/healthinfo/hic.asp

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Massachusetts: Baystate Medical Center Library (Baystate Health System), http://www.baystatehealth.com/1024/

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Massachusetts: Boston University Medical Center Alumni Medical Library (Boston University Medical Center), http://medlibwww.bu.edu/library/lib.html

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Massachusetts: Lowell General Hospital Health Sciences Library (Lowell General Hospital), http://www.lowellgeneral.org/library/HomePageLinks/WWW.htm

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Massachusetts: Paul E. Woodard Health Sciences Library (New England Baptist Hospital), http://www.nebh.org/health_lib.asp

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Massachusetts: St. Luke's Hospital Health Sciences Library (St. Luke's Hospital), http://www.southcoast.org/library/

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Massachusetts: Treadwell Library Consumer Health Reference Center (Massachusetts General Hospital), http://www.mgh.harvard.edu/library/chrcindex.html

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Massachusetts: UMass HealthNet (University of Massachusetts Medical School), http://healthnet.umassmed.edu/

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Michigan: Botsford General Hospital Library - Consumer Health (Botsford General Hospital, Library & Internet Services), http://www.botsfordlibrary.org/consumer.htm

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Michigan: Helen DeRoy Medical Library (Providence Hospital and Medical Centers), http://www.providence-hospital.org/library/

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Michigan: Marquette General Hospital - Consumer Health Library (Marquette General Hospital, Health Information Center), http://www.mgh.org/center.html

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Michigan: Patient Education Resouce Center - University of Michigan Cancer Center (University of Michigan Comprehensive Cancer Center), http://www.cancer.med.umich.edu/learn/leares.htm

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Michigan: Sladen Library & Center for Health Information Resources Consumer Health Information, http://www.sladen.hfhs.org/library/consumer/index.html

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Montana: Center for Health Information (St. Patrick Hospital and Health Sciences Center), http://www.saintpatrick.org/chi/librarydetail.php3?ID=41


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National: Consumer Health Library Directory (Medical Library Association, Consumer and Patient Health Information Section), http://caphis.mlanet.org/directory/index.html

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National: National Network of Libraries of Medicine (National Library of Medicine) - provides library services for health professionals in the United States who do not have access to a medical library, http://nnlm.gov/

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National: NN/LM List of Libraries Serving the Public (National Network of Libraries of Medicine), http://nnlm.gov/members/

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Nevada: Health Science Library, West Charleston Library (Las Vegas Clark County Library District), http://www.lvccld.org/special_collections/medical/index.htm

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New Hampshire: Dartmouth Biomedical Libraries (Dartmouth College Library), http://www.dartmouth.edu/~biomed/resources.htmld/conshealth.htmld /

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New Jersey: Consumer Health Library (Rahway Hospital), http://www.rahwayhospital.com/library.htm

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New Jersey: Dr. Walter Phillips Health Sciences Library (Englewood Hospital and Medical Center), http://www.englewoodhospital.com/links/index.htm

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New Jersey: Meland Foundation (Englewood Hospital and Medical Center), http://www.geocities.com/ResearchTriangle/9360/

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New York: Choices in Health Information (New York Public Library) NLM Consumer Pilot Project participant, http://www.nypl.org/branch/health/links.html

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New York: Health Information Center (Upstate Medical University, State University of New York), http://www.upstate.edu/library/hic/

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New York: Health Sciences Library (Long Island Jewish Medical Center), http://www.lij.edu/library/library.html

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New York: ViaHealth Medical Library (Rochester General Hospital), http://www.nyam.org/library/

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Ohio: Consumer Health Library (Akron General Medical Center, Medical & Consumer Health Library), http://www.akrongeneral.org/hwlibrary.htm

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Oklahoma: Saint Francis Health System Patient/Family Resource Center (Saint Francis Health System), http://www.sfhtulsa.com/patientfamilycenter/default.asp


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Oregon: Planetree Health Resource Center (Mid-Columbia Medical Center), http://www.mcmc.net/phrc/

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Pennsylvania: Community Health Information Library (Milton S. Hershey Medical Center), http://www.hmc.psu.edu/commhealth/

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Pennsylvania: Community Health Resource Library (Geisinger Medical Center), http://www.geisinger.edu/education/commlib.shtml

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Pennsylvania: HealthInfo Library (Moses Taylor Hospital), http://www.mth.org/healthwellness.html

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Pennsylvania: Hopwood Library (University of Pittsburgh, Health Sciences Library System), http://www.hsls.pitt.edu/chi/hhrcinfo.html

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Pennsylvania: Koop Community Health Information Center (College of Physicians of Philadelphia), http://www.collphyphil.org/kooppg1.shtml

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Pennsylvania: Learning Resources Center - Medical Library (Susquehanna Health System), http://www.shscares.org/services/lrc/index.asp

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Pennsylvania: Medical Library (UPMC Health System), http://www.upmc.edu/passavant/library.htm

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Quebec, Canada: Medical Library (Montreal General Hospital), http://ww2.mcgill.ca/mghlib/

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South Dakota: Rapid City Regional Hospital - Health Information Center (Rapid City Regional Hospital, Health Information Center), http://www.rcrh.org/education/LibraryResourcesConsumers.htm

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Texas: Houston HealthWays (Houston Academy of Medicine-Texas Medical Center Library), http://hhw.library.tmc.edu/

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Texas: Matustik Family Resource Center (Cook Children's Health Care System), http://www.cookchildrens.com/Matustik_Library.html

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Washington: Community Health Library (Kittitas Valley Community Hospital), http://www.kvch.com/

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Washington: Southwest Washington Medical Center Library (Southwest Washington Medical Center), http://www.swmedctr.com/Home/

Principles of Drug Addiction Treatment 167

APPENDIX E. TREATMENT

PRINCIPLES

OF

DRUG

ADDICTION

Overview59 No single treatment is appropriate for all individuals. Matching treatment settings, interventions, and services to each individual's particular problems and needs is critical to his or her ultimate success in returning to productive functioning in the family, workplace, and society. This appendix reproduces information created by the National Institute for Drug Abuse (NIDA) concerning drug abuse treatment entitled “Principles of Drug Addiction Treatment: A Research-Based Guide”.

Principles of Effective Treatment Treatment needs to be readily available. Because individuals who are addicted to drugs may be uncertain about entering treatment, taking advantage of opportunities when they are ready for treatment is crucial. Potential treatment applicants can be lost if treatment is not immediately available or is not readily accessible. Effective treatment attends to multiple needs of the individual, not just his or her drug use. To be effective, treatment must address the individual's drug use and any associated medical, psychological, social, vocational, and legal problems.

Adapted from the National Institute on Drug Abuse: http://165.112.78.61/PODAT/PODATIndex.html.

59


An individual's treatment and services plan must be assessed continually and modified as necessary to ensure that the plan meets the person's changing needs. A patient may require varying combinations of services and treatment components during the course of treatment and recovery. In addition to counseling or psychotherapy, a patient at times may require medication, other medical services, family therapy, parenting instruction, vocational rehabilitation, and social and legal services. It is critical that the treatment approach be appropriate to the individual's age, gender, ethnicity, and culture. Remaining in treatment for an adequate period of time is critical for treatment effectiveness. The appropriate duration for an individual depends on his or her problems and needs. Research indicates that for most patients, the threshold of significant improvement is reached at about 3 months in treatment. After this threshold is reached, additional treatment can produce further progress toward recovery. Because people often leave treatment prematurely, programs should include strategies to engage and keep patients in treatment. Counseling and Other Behavioral Therapies Counseling (individual and/or group) and other behavioral therapies are critical components of effective treatment for addiction. In therapy, patients address issues of motivation, build skills to resist drug use, replace drugusing activities with constructive and rewarding non-drug-using activities, and improve problem-solving abilities. Behavioral therapy also facilitates interpersonal relationships and the individual's ability to function in the family and community.

Medications Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioral therapies. Methadone and levo-alpha-acetylmethadol (LAAM) are very effective in helping individuals addicted to heroin or other opiates stabilize their lives and reduce their illicit drug use. Naltrexone is also an effective medication for some opiate addicts and some patients with co-occurring alcohol dependence. For persons addicted to nicotine, a nicotine replacement product (such as patches or gum) or an oral medication (such as bupropion) can be an effective component of treatment. For patients with mental


disorders, both behavioral treatments and medications can be critically important.

Patients with Mental Disorders Addicted or drug-abusing individuals with coexisting mental disorders should have both disorders treated in an integrated way. Because addictive disorders and mental disorders often occur in the same individual, patients presenting for either condition should be assessed and treated for the cooccurrence of the other type of disorder.

Medical Detoxification Medical detoxification is only the first stage of addiction treatment and by itself does little to change long-term drug use. Medical detoxification safely manages the acute physical symptoms of withdrawal associated with stopping drug use. While detoxification alone is rarely sufficient to help addicts achieve long-term abstinence, for some individuals it is a strongly indicated precursor to effective drug addiction treatment.

Patient Cooperation Treatment does not need to be voluntary to be effective. Strong motivation can facilitate the treatment process. Sanctions or enticements in the family, employment setting, or criminal justice system can increase significantly both treatment entry and retention rates and the success of drug treatment interventions. Possible drug use during treatment must be monitored continuously. Lapses to drug use can occur during treatment. The objective monitoring of a patient's drug and alcohol use during treatment, such as through urinalysis or other tests, can help the patient withstand urges to use drugs. Such monitoring also can provide early evidence of drug use so that the individual's treatment plan can be adjusted. Feedback to patients who test positive for illicit drug use is an important element of monitoring. Treatment programs should provide assessment for HIV/AIDS, hepatitis B and C, tuberculosis and other infectious diseases, and counseling to help patients modify or change behaviors that place themselves or others at risk of infection. Counseling can help patients avoid high-risk behavior.


Counseling also can help people who are already infected manage their illness.

Recovery Recovery from drug addiction can be a long-term process and frequently requires multiple episodes of treatment. As with other chronic illnesses, relapses to drug use can occur during or after successful treatment episodes. Addicted individuals may require prolonged treatment and multiple episodes of treatment to achieve long-term abstinence and fully restored functioning. Participation in self-help support programs during and following treatment often is helpful in maintaining abstinence.

What Is Drug Addiction? Drug addiction is a complex illness. It is characterized by compulsive, at times uncontrollable, drug craving, seeking, and use that persist even in the face of extremely negative consequences. For many people, drug addiction becomes chronic, with relapses possible even after long periods of abstinence. The path to drug addiction begins with the act of taking drugs. Over time, a person's ability to choose not to take drugs can be compromised. Drug seeking becomes compulsive, in large part as a result of the effects of prolonged drug use on brain functioning and, thus, on behavior. The compulsion to use drugs can take over the individual's life. Addiction often involves not only compulsive drug taking but also a wide range of dysfunctional behaviors that can interfere with normal functioning in the family, the workplace, and the broader community. Addiction also can place people at increased risk for a wide variety of other illnesses. These illnesses can be brought on by behaviors, such as poor living and health habits, that often accompany life as an addict, or because of toxic effects of the drugs themselves. Because addiction has so many dimensions and disrupts so many aspects of an individual's life, treatment for this illness is never simple. Drug treatment must help the individual stop using drugs and maintain a drug-free lifestyle, while achieving productive functioning in the family, at work, and in society. Effective drug abuse and addiction treatment programs typically


incorporate many components, each directed to a particular aspect of the illness and its consequences. Three decades of scientific research and clinical practice have yielded a variety of effective approaches to drug addiction treatment. Extensive data document that drug addiction treatment is as effective as are treatments for most other similarly chronic medical conditions. In spite of scientific evidence that establishes the effectiveness of drug abuse treatment, many people believe that treatment is ineffective. In part, this is because of unrealistic expectations. Many people equate addiction with simply using drugs and therefore expect that addiction should be cured quickly, and if it is not, treatment is a failure. In reality, because addiction is a chronic disorder, the ultimate goal of long-term abstinence often requires sustained and repeated treatment episodes. Of course, not all drug abuse treatment is equally effective. Research also has revealed a set of overarching principles that characterize the most effective drug abuse and addiction treatments and their implementation. Treatment varies depending on the type of drug and the characteristics of the patient. The best programs provide a combination of therapies and other services.

Frequently Asked Questions What Is Drug Addiction Treatment? ·

There are many addictive drugs, and treatments for specific drugs can differ. Treatment also varies depending on the characteristics of the patient.

·

Problems associated with an individual's drug addiction can vary significantly. People who are addicted to drugs come from all walks of life. Many suffer from mental health, occupational, health, or social problems that make their addictive disorders much more difficult to treat. Even if there are few associated problems, the severity of addiction itself ranges widely among people.

·

A variety of scientifically based approaches to drug addiction treatment exist. Drug addiction treatment can include behavioral therapy (such as counseling, cognitive therapy, or psychotherapy), medications, or their combination. Behavioral therapies offer people strategies for coping with their drug cravings, teach them ways to avoid drugs and prevent relapse,


and help them deal with relapse if it occurs. When a person's drugrelated behavior places him or her at higher risk for AIDS or other infectious diseases, behavioral therapies can help to reduce the risk of disease transmission. Case management and referral to other medical, psychological, and social services are crucial components of treatment for many patients. The best programs provide a combination of therapies and other services to meet the needs of the individual patient, which are shaped by such issues as age, race, culture, sexual orientation, gender, pregnancy, parenting, housing, and employment, as well as physical and sexual abuse. ·

Treatment medications, such as methadone, LAAM, and naltrexone, are available for individuals addicted to opiates. Nicotine preparations (patches, gum, nasal spray) and bupropion are available for individuals addicted to nicotine.

·

The best treatment programs provide a combination of therapies and other services to meet the needs of the individual patient. CHILD CARE SERVICES FAMILY SERVICES

FINANCIAL SERVICES

VOCATIONAL SERVICES

P ROCESSING / A SSESSEMENT

HOUSING/ TRANSPORTATION SERVICES

INTAKE

B EHAVIORAL T HERAPY AND C OUNSELING

T REATMENT P LAN

S UBSTANCE U SE MONITORING

C LINICAL AND C ASE MANAGEMENT

P HARMACOTHERAPY

S ELF -H ELP /P EER S UPPORT G ROUPS

MENTAL HEALTH SERVICES

MEDI CAL SERVICES

C ONTINUING C ARE LEGAL

EDUCATIONAL SERVICES

SERVICES AIDS/HIV SERVICES

Components of Comprehensive Drug Abuse Treatment ·

Medications, such as antidepressants, mood stabilizers, or neuroleptics, may be critical for treatment success when patients have co-occurring mental disorders, such as depression, anxiety disorder, bipolar disorder, or psychosis.

·

Treatment can occur in a variety of settings, in many different forms, and for different lengths of time. Because drug addiction is typically a chronic disorder characterized by occasional relapses, a short-term, one-time treatment often is not sufficient. For many, treatment is a long-term process that involves multiple interventions and attempts at abstinence.


Why Can't Drug Addicts Quit on Their Own? Nearly all addicted individuals believe in the beginning that they can stop using drugs on their own, and most try to stop without treatment. However, most of these attempts result in failure to achieve long-term abstinence. Research has shown that long-term drug use results in significant changes in brain function that persist long after the individual stops using drugs. These drug-induced changes in brain function may have many behavioral consequences, including the compulsion to use drugs despite adverse consequences. This is the defining characteristic of addiction. Understanding that addiction has such an important biological component may help explain an individual's difficulty in achieving and maintaining abstinence without treatment. Psychological stress from work or family problems, social cues (such as meeting individuals from one's drug-using past), or the environment (such as encountering streets, objects, or even smells associated with drug use) can interact with biological factors to hinder attainment of sustained abstinence and make relapse more likely. Research studies indicate that even the most severely addicted individuals can participate actively in treatment and that active participation is essential to good outcomes. How Effective Is Drug Addiction Treatment? In addition to stopping drug use, the goal of treatment is to return the individual to productive functioning in the family, workplace, and community. Measures of effectiveness typically include levels of criminal behavior, family functioning, employability, and medical condition. Overall, treatment of addiction is as successful as treatment of other chronic diseases, such as diabetes, hypertension, and asthma. Treatment of addiction is as successful as treatment of other chronic diseases such as diabetes, hypertension, and asthma. According to several studies, drug treatment reduces drug use by 40 to 60 percent and significantly decreases criminal activity during and after treatment. For example, a study of therapeutic community treatment for drug offenders demonstrated that arrests for violent and nonviolent criminal acts were reduced by 40 percent or more. Methadone treatment has been shown to decrease criminal behavior by as much as 50 percent. Research shows that drug addiction treatment reduces the risk of HIV infection and that interventions to prevent HIV are much less costly than treating HIV-related illnesses. Treatment can


improve the prospects for employment, with gains of up to 40 percent after treatment. Although these effectiveness rates hold in general, individual treatment outcomes depend on the extent and nature of the patient's presenting problems, the appropriateness of the treatment components and related services used to address those problems, and the degree of active engagement of the patient in the treatment process.

How Long Does Drug Addiction Treatment Usually Last? Individuals progress through drug addiction treatment at various speeds, so there is no predetermined length of treatment. However, research has shown unequivocally that good outcomes are contingent on adequate lengths of treatment. Generally, for residential or outpatient treatment, participation for less than 90 days is of limited or no effectiveness, and treatments lasting significantly longer often are indicated. For methadone maintenance, 12 months of treatment is the minimum, and some opiate-addicted individuals will continue to benefit from methadone maintenance treatment over a period of years. Good outcomes are contingent on adequate lengths of treatment. Many people who enter treatment drop out before receiving all the benefits that treatment can provide. Successful outcomes may require more than one treatment experience. Many addicted individuals have multiple episodes of treatment, often with a cumulative impact.

What Helps People Stay in Treatment? Since successful outcomes often depend upon retaining the person long enough to gain the full benefits of treatment, strategies for keeping an individual in the program are critical. Whether a patient stays in treatment depends on factors associated with both the individual and the program. Individual factors related to engagement and retention include motivation to change drug-using behavior, degree of support from family and friends, and whether there is pressure to stay in treatment from the criminal justice system, child protection services, employers, or the family. Within the program, successful counselors are able to establish a positive, therapeutic relationship with the patient. The counselor should ensure that a treatment plan is established and followed so that the individual knows what to expect


during treatment. Medical, psychiatric, and social services should be available. Whether a patient stays in treatment depends on factors associated with both the individual and the program. Since some individual problems (such as serious mental illness, severe cocaine or crack use, and criminal involvement) increase the likelihood of a patient dropping out, intensive treatment with a range of components may be required to retain patients who have these problems. The provider then should ensure a transition to continuing care or “aftercare” following the patient's completion of formal treatment. Is the Use of Medications Like Methadone Simply Replacing One Drug Addiction with Another? No. As used in maintenance treatment, methadone and LAAM are not heroin substitutes. They are safe and effective medications for opiate addiction that are administered by mouth in regular, fixed doses. Their pharmacological effects are markedly different from those of heroin. Injected, snorted, or smoked heroin causes an almost immediate “rush” or brief period of euphoria that wears off very quickly, terminating in a “crash.” The individual then experiences an intense craving to use more heroin to stop the crash and reinstate the euphoria. The cycle of euphoria, crash, and craving is repeated several times a day which leads to a cycle of addiction and behavioral disruption. These characteristics of heroin use result from the drug's rapid onset of action and its short duration of action in the brain. An individual who uses heroin multiple times per day subjects his or her brain and body to marked, rapid fluctuations as the opiate effects come and go. These fluctuations can disrupt a number of important bodily functions. Because heroin is illegal, addicted persons often become part of a volatile drug-using street culture characterized by hustling and crimes for profit. Methadone and LAAM have far more gradual onsets of action than heroin, and as a result, patients stabilized on these medications do not experience any rush. In addition, both medications wear off much more slowly than heroin, so there is no sudden crash, and the brain and body are not exposed to the marked fluctuations seen with heroin use. Maintenance treatment with methadone or LAAM markedly reduces the desire for heroin. If an individual maintained on adequate, regular doses of methadone (once a day) or LAAM (several times per week) tries to take heroin, the euphoric effects


of heroin will be significantly blocked. According to research, patients undergoing maintenance treatment do not suffer the medical abnormalities and behavioral destabilization that rapid fluctuations in drug levels cause in heroin addicts.

What Role Can the Criminal Justice System Play in the Treatment of Drug Addiction? Increasingly, research is demonstrating that treatment for drug-addicted offenders during and after incarceration can have a significant beneficial effect upon future drug use, criminal behavior, and social functioning. The case for integrating drug addiction treatment approaches with the criminal justice system is compelling. Combining prison- and community-based treatment for drug-addicted offenders reduces the risk of both recidivism to drug-related criminal behavior and relapse to drug use. For example, a recent study found that prisoners who participated in a therapeutic treatment program in the Delaware State Prison and continued to receive treatment in a work-release program after prison were 70 percent less likely than non-participants to return to drug use and incur rearrest. Individuals who enter treatment under legal pressure have outcomes as favorable as those who enter treatment voluntarily. The majority of offenders involved with the criminal justice system are not in prison but are under community supervision. For those with known drug problems, drug addiction treatment may be recommended or mandated as a condition of probation. Research has demonstrated that individuals who enter treatment under legal pressure have outcomes as favorable as those who enter treatment voluntarily. The criminal justice system refers drug offenders into treatment through a variety of mechanisms, such as diverting nonviolent offenders to treatment, stipulating treatment as a condition of probation or pretrial release, and convening specialized courts that handle cases for offenses involving drugs. Drug courts, another model, are dedicated to drug offender cases. They mandate and arrange for treatment as an alternative to incarceration, actively monitor progress in treatment, and arrange for other services to drug-involved offenders. The most effective models integrate criminal justice and drug treatment systems and services. Treatment and criminal justice personnel work together on plans and implementation of screening, placement, testing, monitoring, and supervision, as well as on the systematic use of sanctions


and rewards for drug abusers in the criminal justice system. Treatment for incarcerated drug abusers must include continuing care, monitoring, and supervision after release and during parole. How Does Drug Addiction Treatment Help Reduce the Spread of HIV/AIDS and Other Infectious Diseases? Many drug addicts, such as heroin or cocaine addicts and particularly injection drug users, are at increased risk for HIV/AIDS as well as other infectious diseases like hepatitis, tuberculosis, and sexually transmitted infections. For these individuals and the community at large, drug addiction treatment is disease prevention. Drug injectors who do not enter treatment are up to six times more likely to become infected with HIV than injectors who enter and remain in treatment. Drug users who enter and continue in treatment reduce activities that can spread disease, such as sharing injection equipment and engaging in unprotected sexual activity. Participation in treatment also presents opportunities for screening, counseling, and referral for additional services. The best drug abuse treatment programs provide HIV counseling and offer HIV testing to their patients.

Where Do 12-Step or Self-Help Programs Fit into Drug Addiction Treatment? Self-help groups can complement and extend the effects of professional treatment. The most prominent self-help groups are those affiliated with Alcoholics Anonymous (AA), Narcotics Anonymous (NA), and Cocaine Anonymous (CA), all of which are based on the 12-step model, and Smart Recovery®. Most drug addiction treatment programs encourage patients to participate in a self-help group during and after formal treatment.

How Can Families and Friends Make a Difference in the Life of Someone Needing Treatment? Family and friends can play critical roles in motivating individuals with drug problems to enter and stay in treatment. Family therapy is important, especially for adolescents. Involvement of a family member in an individual's treatment program can strengthen and extend the benefits of the program.


Is Drug Addiction Treatment Worth Its Cost? Drug addiction treatment is cost-effective in reducing drug use and its associated health and social costs. Treatment is less expensive than alternatives, such as not treating addicts or simply incarcerating addicts. For example, the average cost for 1 full year of methadone maintenance treatment is approximately $4,700 per patient, whereas 1 full year of imprisonment costs approximately $18,400 per person. According to several conservative estimates, every $1 invested in addiction treatment programs yields a return of between $4 and $7 in reduced drugrelated crime, criminal justice costs, and theft alone. When savings related to health care are included, total savings can exceed costs by a ratio of 12 to 1. Major savings to the individual and society also come from significant drops in interpersonal conflicts, improvements in workplace productivity, and reductions in drug-related accidents.

Drug Addiction Treatment in the United States Drug addiction is a complex disorder that can involve virtually every aspect of an individual's function in the family, at work, and in the community. Because of addiction's complexity and pervasive consequences, drug addiction treatment typically must involve many components. Some of those components focus directly on the individual's drug use. Others, like employment training, focus on restoring the addicted individual to productive membership in the family and society. Treatment for drug abuse and addiction is delivered in many different settings, using a variety of behavioral and pharmacological approaches. In the United States, more than 11,000 specialized drug treatment facilities provide rehabilitation, counseling, behavioral therapy, medication, case management, and other types of services to persons with drug use disorders. Because drug abuse and addiction are major public health problems, a large portion of drug treatment is funded by local, State, and Federal governments. Private and employer-subsidized health plans also may provide coverage for treatment of drug addiction and its medical consequences. Drug abuse and addiction are treated in specialized treatment facilities and mental health clinics by a variety of providers, including certified drug abuse counselors, physicians, psychologists, nurses, and social workers. Treatment


is delivered in outpatient, inpatient, and residential settings. Although specific treatment approaches often are associated with particular treatment settings, a variety of therapeutic interventions or services can be included in any given setting.

General Categories of Treatment Programs Research studies on drug addiction treatment have typically classified treatment programs into several general types or modalities, which are described in the following text. Treatment approaches and individual programs continue to evolve, and many programs in existence today do not fit neatly into traditional drug addiction treatment classifications.

Agonist Maintenance Treatment Agonist maintenance treatment for opiate addicts usually is conducted in outpatient settings, often called methadone treatment programs. These programs use a long-acting synthetic opiate medication, usually methadone or LAAM, administered orally for a sustained period at a dosage sufficient to prevent opiate withdrawal, block the effects of illicit opiate use, and decrease opiate craving. Patients stabilized on adequate, sustained dosages of methadone or LAAM can function normally. They can hold jobs, avoid the crime and violence of the street culture, and reduce their exposure to HIV by stopping or decreasing injection drug use and drug-related high-risk sexual behavior. Patients stabilized on opiate agonists can engage more readily in counseling and other behavioral interventions essential to recovery and rehabilitation. The best, most effective opiate agonist maintenance programs include individual and/or group counseling, as well as provision of, or referral to, other needed medical, psychological, and social services. Narcotic Antagonist Treatment Using Naltrexone Narcotic antagonist treatment using Naltrexone for opiate addicts usually is conducted in outpatient settings although initiation of the medication often begins after medical detoxification in a residential setting. Naltrexone is a long-acting synthetic opiate antagonist with few side effects that is taken orally either daily or three times a week for a sustained period of time. Individuals must be medically detoxified and opiate-free for several days before Naltrexone can be taken to prevent precipitating an opiate abstinence


syndrome. When used this way, all the effects of self-administered opiates, including euphoria, are completely blocked. The theory behind this treatment is that the repeated lack of the desired opiate effects, as well as the perceived futility of using the opiate, will gradually over time result in breaking the habit of opiate addiction. Naltrexone itself has no subjective effects or potential for abuse and is not addicting. Patient noncompliance is a common problem. Therefore, a favorable treatment outcome requires that there also be a positive therapeutic relationship, effective counseling or therapy, and careful monitoring of medication compliance. Patients stabilized on Naltrexone can hold jobs, avoid crime and violence, and reduce their exposure to HIV. Many experienced clinicians have found Naltrexone most useful for highly motivated, recently detoxified patients who desire total abstinence because of external circumstances, including impaired professionals, parolees, probationers, and prisoners in workrelease status. Patients stabilized on Naltrexone can function normally. They can hold jobs, avoid the crime and violence of the street culture, and reduce their exposure to HIV by stopping injection drug use and drug-related highrisk sexual behavior.

Outpatient Drug-Free Treatment Outpatient drug-free treatment in the types and intensity of services offered. Such treatment costs less than residential or inpatient treatment and often is more suitable for individuals who are employed or who have extensive social supports. Low-intensity programs may offer little more than drug education and admonition. Other outpatient models, such as intensive day treatment, can be comparable to residential programs in services and effectiveness, depending on the individual patient's characteristics and needs. In many outpatient programs, group counseling is emphasized. Some outpatient programs are designed to treat patients who have medical or mental health problems in addition to their drug disorder.

Long-Term Residential Treatment Long-term residential treatment provides care 24 hours per day, generally in non-hospital settings. The best-known residential treatment model is the therapeutic community (TC), but residential treatment may also employ other models, such as cognitive-behavioral therapy.


TCs are residential programs with planned lengths of stay of 6 to 12 months. TCs focus on the “resocialization” of the individual and use the program's entire “community,” including other residents, staff, and the social context, as active components of treatment. Addiction is viewed in the context of an individual's social and psychological deficits, and treatment focuses on developing personal accountability and responsibility and socially productive lives. Treatment is highly structured and can at times be confrontational, with activities designed to help residents examine damaging beliefs, self-concepts, and patterns of behavior and to adopt new, more harmonious and constructive ways to interact with others. Many TCs are quite comprehensive and can include employment training and other support services on site. Compared with patients in other forms of drug treatment, the typical TC resident has more severe problems, with more co-occurring mental health problems and more criminal involvement. Research shows that TCs can be modified to treat individuals with special needs, including adolescents, women, those with severe mental disorders, and individuals in the criminal justice system.

Short-Term Residential Programs Short-term residential programs provide intensive but relatively brief residential treatment based on a modified 12-step approach. These programs were originally designed to treat alcohol problems, but during the cocaine epidemic of the mid-1980's, many began to treat illicit drug abuse and addiction. The original residential treatment model consisted of a 3 to 6 week hospital-based inpatient treatment phase followed by extended outpatient therapy and participation in a self-help group, such as Alcoholics Anonymous. Reduced health care coverage for substance abuse treatment has resulted in a diminished number of these programs, and the average length of stay under managed care review is much shorter than in early programs.

Medical Detoxification Medical Detoxification is a process whereby individuals are systematically withdrawn from addicting drugs in an inpatient or outpatient setting, typically under the care of a physician. Detoxification is sometimes called a distinct treatment modality but is more appropriately considered a precursor of treatment, because it is designed to treat the acute physiological effects of


stopping drug use. Medications are available for detoxification from opiates, nicotine, benzodiazepines, alcohol, barbiturates, and other sedatives. In some cases, particularly for the last three types of drugs, detoxification may be a medical necessity, and untreated withdrawal may be medically dangerous or even fatal. Detoxification is not designed to address the psychological, social, and behavioral problems associated with addiction and therefore does not typically produce lasting behavioral changes necessary for recovery. Detoxification is most useful when it incorporates formal processes of assessment and referral to subsequent drug addiction treatment.

Treating Criminal Justice-Involved Drug Abusers and Addicts Research has shown that combining criminal justice sanctions with drug treatment can be effective in decreasing drug use and related crime. Individuals under legal coercion tend to stay in treatment for a longer period of time and do as well as or better than others not under legal pressure. Often, drug abusers come into contact with the criminal justice system earlier than other health or social systems, and intervention by the criminal justice system to engage the individual in treatment may help interrupt and shorten a career of drug use. Treatment for the criminal justice-involved drug abuser or drug addict may be delivered prior to, during, after, or in lieu of incarceration. Combining criminal justice sanctions with drug treatment can be effective in decreasing drug use and related crime.

Prison-Based Treatment Programs Offenders with drug disorders may encounter a number of treatment options while incarcerated, including didactic drug education classes, selfhelp programs, and treatment based on therapeutic community or residential milieu therapy models. The TC model has been studied extensively and can be quite effective in reducing drug use and recidivism to criminal behavior. Those in treatment should be segregated from the general prison population, so that the “prison culture” does not overwhelm progress toward recovery. As might be expected, treatment gains can be lost if inmates are returned to the general prison population after treatment. Research shows that relapse to drug use and recidivism to crime are


significantly lower if the drug offender continues treatment after returning to the community.

Community-Based Treatment for Criminal Justice Populations A number of criminal justice alternatives to incarceration have been tried with offenders who have drug disorders, including limited diversion programs, pretrial release conditional on entry into treatment, and conditional probation with sanctions. The drug court is a promising approach. Drug courts mandate and arrange for drug addiction treatment, actively monitor progress in treatment, and arrange for other services to drug-involved offenders. Federal support for planning, implementation, and enhancement of drug courts is provided under the U.S. Department of Justice Drug Courts Program Office. As a well-studied example, the Treatment Accountability and Safer Communities (TASC) program provides an alternative to incarceration by addressing the multiple needs of drug-addicted offenders in a communitybased setting. TASC programs typically include counseling, medical care, parenting instruction, family counseling, school and job training, and legal and employment services. The key features of TASC include: ·

Coordination of criminal justice and drug treatment;

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Early identification, assessment, and referral of drug-involved offenders;

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Monitoring offenders through drug testing; and

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Use of legal sanctions as inducements to remain in treatment.

Scientifically-Based Approaches to Drug Addiction Treatment This section presents several examples of treatment approaches and components that have been developed and tested for efficacy through research supported by the National Institute on Drug Abuse (NIDA). Each approach is designed to address certain aspects of drug addiction and its consequences for the individual, family, and society. The approaches are to be used to supplement or enhance (not replace) existing treatment programs. This section is not a complete list of efficacious, scientifically-based treatment approaches. Additional approaches are under development as part of NIDA's continuing support of treatment research.


Relapse Prevention Relapse prevention, a cognitive-behavioral therapy, was developed for the treatment of problem drinking and adapted later for cocaine addicts. Cognitive-behavioral strategies are based on the theory that learning processes play a critical role in the development of maladaptive behavioral patterns. Individuals learn to identify and correct problematic behaviors. Relapse prevention encompasses several cognitive-behavioral strategies that facilitate abstinence as well as provide help for people who experience relapse. The relapse prevention approach to the treatment of cocaine addiction consists of a collection of strategies intended to enhance self-control. Specific techniques include exploring the positive and negative consequences of continued use, self-monitoring to recognize drug cravings early on and to identify high-risk situations for use, and developing strategies for coping with and avoiding high-risk situations and the desire to use. A central element of this treatment is anticipating the problems patients are likely to meet and helping them develop effective coping strategies. Research indicates that the skills individuals learn through relapse prevention therapy remain after the completion of treatment. In one study, most people receiving this cognitive-behavioral approach maintained the gains they made in treatment throughout the year following treatment.

The Matrix Model The Matrix model provides a framework for engaging stimulant abusers in treatment and helping them achieve abstinence. Patients learn about issues critical to addiction and relapse, receive direction and support from a trained therapist, become familiar with self-help programs, and are monitored for drug use by urine testing. The program includes education for family members affected by the addiction. The therapist functions simultaneously as teacher and coach, fostering a positive, encouraging relationship with the patient and using that relationship to reinforce positive behavior change. The interaction between the therapist and the patient is realistic and direct but not confrontational or parental. Therapists are trained to conduct treatment sessions in a way that promotes the patient's self-esteem, dignity, and self-worth. A positive relationship between patient and therapist is a critical element for patient retention.


Treatment materials draw heavily on other tested treatment approaches. Thus, this approach includes elements pertaining to the areas of relapse prevention, family and group therapies, drug education, and self-help participation. Detailed treatment manuals contain work sheets for individual sessions; other components include family educational groups, early recovery skills groups, relapse prevention groups, conjoint sessions, urine tests, 12-step programs, relapse analysis, and social support groups. A number of projects have demonstrated that participants treated with the Matrix model demonstrate statistically significant reductions in drug and alcohol use, improvements in psychological indicators, and reduced risky sexual behaviors associated with HIV transmission. These reports, along with evidence suggesting comparable treatment response for methamphetamine users and cocaine users and demonstrated efficacy in enhancing naltrexone treatment of opiate addicts, provide a body of empirical support for the use of the model.

Supportive-Expressive Psychotherapy Supportive-expressive psychotherapy is a time-limited, focused psychotherapy that has been adapted for heroin- and cocaine-addicted individuals. The therapy has two main components: ·

Supportive techniques to help patients feel comfortable in discussing their personal experiences.

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Expressive techniques to help patients identify and work through interpersonal relationship issues.

Special attention is paid to the role of drugs in relation to problem feelings and behaviors, and how problems may be solved without recourse to drugs. The efficacy of individual supportive-expressive psychotherapy has been tested with patients in methadone maintenance treatment who had psychiatric problems. In a comparison with patients receiving only drug counseling, both groups fared similarly with regard to opiate use, but the supportive-expressive psychotherapy group had lower cocaine use and required less methadone. Also, the patients who received supportiveexpressive psychotherapy maintained many of the gains they had made. In an earlier study, supportive-expressive psychotherapy, when added to drug counseling, improved outcomes for opiate addicts in methadone treatment with moderately severe psychiatric problems.


Individualized Drug Counseling Individualized drug counseling focuses directly on reducing or stopping the addict's illicit drug use. It also addresses related areas of impaired functioning such as employment status, illegal activity, family/social relations as well as the content and structure of the patient's recovery program. Through its emphasis on short-term behavioral goals, individualized drug counseling helps the patient develop coping strategies and tools for abstaining from drug use and then maintaining abstinence. The addiction counselor encourages 12-step participation and makes referrals for needed supplemental medical, psychiatric, employment, and other services. Individuals are encouraged to attend sessions one or two times per week. In a study that compared opiate addicts receiving only methadone to those receiving methadone coupled with counseling, individuals who received only methadone showed minimal improvement in reducing opiate use. The addition of counseling produced significantly more improvement. The addition of onsite medical/psychiatric, employment, and family services further improved outcomes. In another study with cocaine addicts, individualized drug counseling, together with group drug counseling, was quite effective in reducing cocaine use. Thus, it appears that this approach has great utility with both heroin and cocaine addicts in outpatient treatment.

Motivational Enhancement Therapy Motivational enhancement therapy is a client-centered counseling approach for initiating behavior change by helping clients to resolve ambivalence about engaging in treatment and stopping drug use. This approach employs strategies to evoke rapid and internally motivated change in the client, rather than guiding the client stepwise through the recovery process. This therapy consists of an initial assessment battery session, followed by two to four individual treatment sessions with a therapist. The first treatment session focuses on providing feedback generated from the initial assessment battery to stimulate discussion regarding personal substance use and to elicit self-motivational statements. Motivational interviewing principles are used to strengthen motivation and build a plan for change. Coping strategies for high-risk situations are suggested and discussed with the client. In subsequent sessions, the therapist monitors change, reviews cessation strategies being used, and continues to encourage


commitment to change or sustained abstinence. Clients are sometimes encouraged to bring a significant other to sessions. This approach has been used successfully with alcoholics and with marijuana-dependent individuals.

Behavioral Therapy Behavioral therapy for Adolescents incorporates the principle that unwanted behavior can be changed by clear demonstration of the desired behavior and consistent reward of incremental steps toward achieving it. Therapeutic activities include fulfilling specific assignments, rehearsing desired behaviors, and recording and reviewing progress, with praise and privileges given for meeting assigned goals. Urine samples are collected regularly to monitor drug use. The therapy aims to equip the patient to gain three types of control: ·

Stimulus Control helps patients avoid situations associated with drug use and learn to spend more time in activities incompatible with drug use.

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Urge Control helps patients recognize and change thoughts, feelings, and plans that lead to drug use.

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Social Control involves family members and other people important in helping patients avoid drugs. A parent or significant other attends treatment sessions when possible and assists with therapy assignments and reinforcing desired behavior.

According to research studies, this therapy helps adolescents become drug free and increases their ability to remain drug free after treatment ends. Adolescents also show improvement in several other areas such as employment/school attendance, family relationships, depression, institutionalization, and alcohol use. Such favorable results are attributed largely to including family members in therapy and rewarding drug abstinence as verified by urinalysis.

Multidimensional Family Therapy (MDFT) for Adolescents Multidimensional family therapy (MDFT) for adolescents is an outpatient family-based drug abuse treatment for teenagers. MDFT views adolescent drug use in terms of a network of influences (that is, individual, family, peer, community) and suggests that reducing unwanted behavior and increasing desirable behavior occur in multiple ways in different settings. Treatment includes individual and family sessions held in the clinic, in the home, or


with family members at the family court, school, or other community locations. During individual sessions, the therapist and adolescent work on important developmental tasks, such as developing decision-making, negotiation, and problem-solving skills. Teenagers acquire skills in communicating their thoughts and feelings to deal better with life stressors, and vocational skills. Parallel sessions are held with family members. Parents examine their particular parenting style, learning to distinguish influence from control and to have a positive and developmentally appropriate influence on their child.

Multisystemic Therapy (MST) Multisystemic therapy (MST) addresses the factors associated with serious antisocial behavior in children and adolescents who abuse drugs. These factors include characteristics of the adolescent (for example, favorable attitudes toward drug use), the family (poor discipline, family conflict, parental drug abuse), peers (positive attitudes toward drug use), school (dropout, poor performance), and neighborhood (criminal subculture). By participating in intense treatment in natural environments (homes, schools, and neighborhood settings) most youths and families complete a full course of treatment. MST significantly reduces adolescent drug use during treatment and for at least 6 months after treatment. Reduced numbers of incarcerations and out-of-home placements of juveniles offset the cost of providing this intensive service and maintaining the clinicians' low caseloads.

Combined Behavioral and Nicotine Replacement Therapy for Nicotine Addiction Combined behavioral and nicotine replacement therapy for nicotine addiction consists of two main components: ·

The transdermal nicotine patch or nicotine gum reduces symptoms of withdrawal, producing better initial abstinence.

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The behavioral component concurrently provides support reinforcement of coping skills, yielding better long-term outcomes.

and

Through behavioral skills training, patients learn to avoid high-risk situations for smoking relapse early on and later to plan strategies to cope with such situations. Patients practice skills in treatment, social, and work


settings. They learn other coping techniques, such as cigarette refusal skills, assertiveness, and time management. The combined treatment is based on the rationale that behavioral and pharmacological treatments operate by different yet complementary mechanisms that produce potentially additive effects.

Community Reinforcement Approach (CRA) Community reinforcement approach (CRA) plus vouchers is an intensive 24week outpatient therapy for treatment of cocaine addiction. The treatment goals are twofold: ·

To achieve cocaine abstinence long enough for patients to learn new life skills that will help sustain abstinence.

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To reduce alcohol consumption for patients whose drinking is associated with cocaine use.

Patients attend one or two individual counseling sessions per week, where they focus on improving family relations, learning a variety of skills to minimize drug use, receiving vocational counseling, and developing new recreational activities and social networks. Those who also abuse alcohol receive clinic-monitored disulfiram (Antabuse) therapy. Patients submit urine samples two or three times each week and receive vouchers for cocaine-negative samples. The value of the vouchers increases with consecutive clean samples. Patients may exchange vouchers for retail goods that are consistent with a cocaine-free lifestyle. This approach facilitates patients' engagement in treatment and systematically aids them in gaining substantial periods of cocaine abstinence. The approach has been tested in urban and rural areas and used successfully in outpatient detoxification of opiate-addicted adults and with inner-city methadone maintenance patients who have high rates of intravenous cocaine abuse.

Voucher-Based Reinforcement Therapy in Methadone Maintenance Treatment Voucher-based reinforcement therapy in Methadone maintenance treatment helps patients achieve and maintain abstinence from illegal drugs by providing them with a voucher each time they provide a drug-free urine sample. The voucher has monetary value and can be exchanged for goods


and services consistent with the goals of treatment. Initially, the voucher values are low, but their value increases with the number of consecutive drug-free urine specimens the individual provides. Cocaine- or heroinpositive urine specimens reset the value of the vouchers to the initial low value. The contingency of escalating incentives is designed specifically to reinforce periods of sustained drug abstinence. Studies show that patients receiving vouchers for drug-free urine samples achieved significantly more weeks of abstinence and significantly more weeks of sustained abstinence than patients who were given vouchers independent of urinalysis results. In another study, urinalyses positive for heroin decreased significantly when the voucher program was started and increased significantly when the program was stopped.

Day Treatment with Abstinence Contingencies and Vouchers Day treatment with abstinence contingencies and vouchers was developed to treat homeless crack addicts. For the first 2 months, participants must spend 5.5 hours daily in the program, which provides lunch and transportation to and from shelters. Interventions include individual assessment and goal setting, individual and group counseling, multiple psycho-educational groups (for example, didactic groups on community resources, housing, cocaine, and HIV/AIDS prevention; establishing and reviewing personal rehabilitation goals; relapse prevention; weekend planning), and patientgoverned community meetings during which patients review contract goals and provide support and encouragement to each other. Individual counseling occurs once a week, and group therapy sessions are held three times a week. After 2 months of day treatment and at least 2 weeks of abstinence, participants graduate to a 4-month work component that pays wages that can be used to rent inexpensive, drug-free housing. A voucher system also rewards drug-free related social and recreational activities. This innovative day treatment was compared with treatment consisting of twice-weekly individual counseling and 12-step groups, medical examinations and treatment, and referral to community resources for housing and vocational services. Innovative day treatment followed by work and housing dependent upon drug abstinence had a more positive effect on alcohol use, cocaine use, and days homeless.


Resources The National Institute on Drug Abuse60 General inquiries: ·

NIDA Public Information Office, Telephone: 301-443-1124.

Inquiries about NIDA's treatment research activities: ·

Division of Treatment Research and Development (301) 443-6173 (for questions regarding behavioral therapies and medications);

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Division of Epidemiology, Services and Prevention Research (301) 4434060 (for questions regarding access to treatment, organization, management, financing, effectiveness and cost-effectiveness).

Center for Substance Abuse Treatment (CSAT) CSAT, a part of the Substance Abuse and Mental Health Services Administration, is responsible for supporting treatment services through block grants and developing knowledge about effective drug treatment, disseminating the findings to the field, and promoting their adoption. CSAT also operates the National Treatment Referral 24-hour Hotline (1-800-662HELP) which offers information and referral to people seeking treatment programs and other assistance. CSAT publications are available through the National Clearinghouse on Alcohol and Drug Information (1-800-729-6686). Additional information can be found at CSAT’s Web Site: http://www.samhsa.gov/csat.

Selected NIDA Educational Resources on Drug Addiction Treatment The following are available from the National Clearinghouse on Alcohol and Drug Information (NCADI), the National Technical Information Service (NTIS), or the Government Printing Office (GPO). To order, refer to the NCADI (1-800-729-6686), NTIS (1-800-553-6847), or GPO (202-512-1800) number provided with the resource description.

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The NIDA: http://www.nida.nih.gov.


Manuals and Clinical Reports ·

Measuring and Improving Cost, Cost-Effectiveness, and Cost-Benefit for Substance Abuse Treatment Programs (1999). Offers substance abuse treatment program managers tools with which to calculate the costs of their programs and investigate the relationship between those costs and treatment outcomes. NCADI # BKD340. Available online at http://www.nida.nih.gov/IMPCOST/IMPCOSTIndex.html.

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A Cognitive-Behavioral Approach: Treating Cocaine Addiction (1998). This is the first in NIDA's “Therapy Manuals for Drug Addiction” series. Describes cognitive-behavioral therapy, a short-term focused approach to helping cocaine-addicted individuals become abstinent from cocaine and other drugs. NCADI # BKD254. Available online at http://www.nida.nih.gov/TXManuals/CBT/CBT1.html.

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A Community Reinforcement Plus Vouchers Approach: Treating Cocaine Addiction (1998). This is the second in NIDA's “Therapy Manuals for Drug Addiction” series. This treatment integrates a community reinforcement approach with an incentive program that uses vouchers. NCADI # BKD255. Available online at http://www.nida.nih.gov/TXManuals/CRA/CRA1.html.

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An Individual Drug Counseling Approach to Treat Cocaine Addiction: The Collaborative Cocaine Treatment Study Model (1999). This is the third in NIDA's “Therapy Manuals for Drug Addiction” series. Describes specific cognitive-behavioral models that can be implemented in a wide range of differing drug abuse treatment settings. NCADI # BKD337. Available online at http://www.nida.nih.gov/TXManuals/IDCA/IDCA1.html.

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Mental Health Assessment and Diagnosis of Substance Abusers: Clinical Report Series (1994). Provides detailed descriptions of psychiatric disorders that can occur among drug-abusing clients. NCADI # BKD148.

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Relapse Prevention: Clinical Report Series (1994). Discusses several major issues to relapse prevention. Provides an overview of factors and experiences that can lead to relapse. Reviews general strategies for preventing relapses, and describes four specific approaches in detail. Outlines administrative issues related to implementing a relapse prevention program. NCADI # BKD147.

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Addiction Severity Index Package (1993). Provides a structured clinical interview designed to collect information about substance use and functioning in life areas from adult clients seeking drug abuse treatment. Includes a handbook for program administrators, a resource manual, two


videotapes, and a training AVA19615VNB2KUS. $150.

facilitator's

manual.

NTIS

#

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Program Evaluation Package (1993). A practical resource for treatment program administrators and key staff. Includes an overview and case study manual, a guide for evaluation, a resource guide, and a pamphlet. NTIS # 95-167268/BDL. $86.50.

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Relapse Prevention Package (1993). Examines two effective relapse prevention models, the Recovery Training and Self-Help (RTSH) program and the Cue Extinction model. NTIS # 95-167250/BDL. $189; GPO # 017-024-01555-5. $57. (Sold by GPO as a set of 7 books)

Research Monographs ·

Beyond the Therapeutic Alliance: Keeping the Drug-Dependent Individual in Treatment (Research Monograph 165) (1997). Reviews current treatment research on the best ways to retain patients in drug abuse treatment. NTIS # 97-181606. $47; GPO # 017-024-01608-0. $17. http://www.nida.nih.gov/pdf/monographs/monograph165/download16 5.html.

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Treatment of Drug-Exposed Women and Children: Advances in Research Methodology (Research Monograph 166) (1997). Presents experiences, products, and procedures of NIDA-supported Treatment Research Demonstration Program projects. NCADI # M166; NTIS # 96179106. $75; GPO # 017-01592-0. $13. Available online at http://www.nida.nih.gov/pdf/monographs/monograph166/download.ht ml.

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Treatment of Drug-Dependent Individuals With Comorbid Mental Disorders (Research Monograph 172) (1997). Promotes effective treatment by reporting state-of-the-art treatment research on individuals with comorbid mental and addictive disorders and research on HIVrelated issues among people with comorbid conditions. NCADI # M172; NTIS # 97-181580. $41; GPO # 017-024-01605. $10. Available online at http://www.nida.nih.gov/pdf/monographs/monograph172/download17 2.html

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Medications Development for the Treatment of Cocaine Dependence: Issues in Clinical Efficacy Trials (Research Monograph 175) (1998). A state-of-the-art handbook for clinical investigators, pharmaceutical scientists, and treatment researchers. NCADI # M175. http://www.nida.nih.gov/pdf/monographs/monograph175/download17 5.html


Videos ·

Adolescent Treatment Approaches (1991). Emphasizes the importance of pinpointing and addressing individual problem areas, such as sexual abuse, peer pressure, and family involvement in treatment. Running time: 25 min. NCADI # VHS40. $12.50.

·

NIDA Technology Transfer Series: Assessment (1991). Shows how to use a number of diagnostic instruments as well as how to assess the implementation and effectiveness of the plan during various phases of the patient's treatment. Running time: 22 min. NCADI # VHS38. $12.50.

·

Drug Abuse Treatment in Prison: A New Way Out (1995). Portrays two comprehensive drug abuse treatment approaches that have been effective with men and women in State and Federal Prisons. Running time: 23 min. NCADI # VHS72. $12.50.

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Dual Diagnosis (1993). Focuses on the problem of mental illness in drugabusing and drug-addicted populations, and examines various approaches useful for treating dual-diagnosed clients. Running time: 27 min. NCADI # VHS58. $12.50.

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LAAM: Another Option for Maintenance Treatment of Opiate Addiction (1995). Shows how LAAM can be used to meet the opiate treatment needs of individual clients from the provider and patient perspectives. Running time: 16 min. NCADI # VHS73. $12.50.

·

Methadone: Where We Are (1993). Examines issues such as the use and effectiveness of methadone as a treatment, biological effects of methadone, the role of the counselor in treatment, and societal attitudes toward methadone treatment and patients. Running time: 24 min. NCADI # VHS59. $12.50.

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Relapse Prevention (1991). Helps practitioners understand the common phenomenon of relapse to drug use among patients in treatment. Running time: 24 min. NCADI # VHS37. $12.50.

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Treatment Issues for Women (1991). Assists treatment counselors help female patients to explore relationships with their children, with men, and with other women. Running time: 22 min. NCADI # VHS39. $12.50.

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Treatment Solutions (1999). Describes the latest developments in treatment research and emphasizes the benefits of drug abuse treatment, not only to the patient, but also to the greater community. Running time: 19 min. NCADI # DD110. $12.50.


·

Program Evaluation Package (1993). A practical resource for treatment program administrators and key staff. Includes an overview and case study manual, a guide for evaluation, a resource guide, and a pamphlet. NTIS # 95-167268/BDL. $86.50.

·

Relapse Prevention Package (1993). Examines two effective relapse prevention models, the Recovery Training and Self-Help (RTSH) program and the Cue Extinction model. NTIS # 95-167250. $189; GPO # 017-024-01555-5. $57. (Sold by GPO as a set of 7 books)

Other Federal Resources ·

The National Clearinghouse for Alcohol and Drug Information (NCADI). NIDA publications and treatment materials along with publications from other Federal agencies are available from this information source. Staff provide assistance in English and Spanish, and have TDD capability. Phone: 1-800-729-6686. Website: http://www.health.org.

·

The National Institute of Justice (NIJ). As the research agency of the Department of Justice, NIJ supports research, evaluation, and demonstration programs relating to drug abuse in the contexts of crime and the criminal justice system. For information, including a wealth of publications, contact the National Criminal Justice Reference Service by telephone (1-800-851-3420 or 1-301-519-5500) or on the World Wide Web (http://www.ojp.usdoj.gov/nij).

Vocabulary Builder The following vocabulary builder gives definitions of words used in this chapter that have not been defined in previous chapters: Antidepressants: A group of drugs used in treating depressive disorders. [NIH]

Bupropion: A unicyclic, aminoketone antidepressant. The mechanism of its therapeutic actions is not well understood, but it does appear to block dopamine uptake. The hydrochloride is available as an aid to smoking cessation treatment. [NIH] Constipation: Infrequent or difficult evacuation of the faeces. [EU] Cues: Signals for an action; that specific portion of a perceptual field or pattern of stimuli to which a subject has learned to respond. [NIH] Hypertension: Persistently high arterial blood pressure. Various criteria for


its threshold have been suggested, ranging from 140 mm. Hg systolic and 90 mm. Hg diastolic to as high as 200 mm. Hg systolic and 110 mm. Hg diastolic. Hypertension may have no known cause (essential or idiopathic h.) or be associated with other primary diseases (secondary h.). [EU] Incarceration: Abnormal retention or confinement of a body part; specifically : a constriction of the neck of a hernial sac so that the hernial contents become irreducible. [EU] Institutionalization: The caring for individuals in institutions and their adaptation to routines characteristic of the institutional environment, and/or their loss of adaptation to life outside the institution. [NIH] Methamphetamine: A central nervous system stimulant and sympathomimetic with actions and uses similar to dextroamphetamine. The smokable form is a drug of abuse and is referred to as crank, crystal, crystal meth, ice, and speed. [NIH] Neuroleptic: A term coined to refer to the effects on cognition and behaviour of antipsychotic drugs, which produce a state of apathy, lack of initiative, and limited range of emotion and in psychotic patients cause a reduction in confusion and agitation and normalization of psychomotor activity. [EU] Precursor: Something that precedes. In biological processes, a substance from which another, usually more active or mature substance is formed. In clinical medicine, a sign or symptom that heralds another. [EU] Respiratory: Pertaining to respiration. [EU] Sedative: 1. allaying activity and excitement. 2. an agent that allays excitement. [EU] Stimulant: 1. producing stimulation; especially producing stimulation by causing tension on muscle fibre through the nervous tissue. 2. an agent or remedy that produces stimulation. [EU] Transdermal: Entering through the dermis, or skin, as in administration of a drug applied to the skin in ointment or patch form. [EU] Urinalysis: Examination of urine by chemical, physical, or microscopic means. Routine urinalysis usually includes performing chemical screening tests, determining specific gravity, observing any unusual color or odor, screening for bacteriuria, and examining the sediment microscopically. [NIH]

Online Glossaries 197

ONLINE GLOSSARIES The Internet provides access to a number of free-to-use medical dictionaries and glossaries. The National Library of Medicine has compiled the following list of online dictionaries: ·

ADAM Medical Encyclopedia (A.D.A.M., Inc.), comprehensive medical reference: http://www.nlm.nih.gov/medlineplus/encyclopedia.html

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MedicineNet.com Medical Dictionary (MedicineNet, Inc.): http://www.medterms.com/Script/Main/hp.asp

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Merriam-Webster Medical Dictionary (Inteli-Health, Inc.): http://www.intelihealth.com/IH/

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Multilingual Glossary of Technical and Popular Medical Terms in Eight European Languages (European Commission) - Danish, Dutch, English, French, German, Italian, Portuguese, and Spanish: http://allserv.rug.ac.be/~rvdstich/eugloss/welcome.html

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On-line Medical Dictionary (CancerWEB): http://www.graylab.ac.uk/omd/

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Technology Glossary (National Library of Medicine) - Health Care Technology: http://www.nlm.nih.gov/nichsr/ta101/ta10108.htm

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Terms and Definitions (Office of Rare Diseases): http://rarediseases.info.nih.gov/ord/glossary_a-e.html

Beyond these, MEDLINEplus contains a very user-friendly encyclopedia covering every aspect of medicine (licensed from A.D.A.M., Inc.). The ADAM Medical Encyclopedia Web site address is http://www.nlm.nih.gov/medlineplus/encyclopedia.html. ADAM is also available on commercial Web sites such as drkoop.com (http://www.drkoop.com/) and Web MD (http://my.webmd.com/adam/asset/adam_disease_articles/a_to_z/a). Topics of interest can be researched by using keywords before continuing elsewhere, as these basic definitions and concepts will be useful in more advanced areas of research. You may choose to print various pages specifically relating to heroin dependence and keep them on file. The NIH, in particular, suggests that patients with heroin dependence visit the following Web sites in the ADAM Medical Encyclopedia: ·

Basic Guidelines for Heroin Dependence


Heroin overdose Web site: http://www.nlm.nih.gov/medlineplus/ency/article/002861.htm ·

Signs & Symptoms for Heroin Dependence Bluish colored fingernails and lips Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003215.htm Coma Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003202.htm Constipation Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003125.htm Drowsiness Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003208.htm Low blood pressure Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003083.htm Muscle spasticity Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003193.htm Spasms Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003193.htm VOMITING Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003117.htm Weak pulse Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003078.htm

Online Glossaries 199

·

Diagnostics and Tests for Heroin Dependence Gastric lavage Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003882.htm Heroin Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003578.htm

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Background Topics for Heroin Dependence Acute Web site: http://www.nlm.nih.gov/medlineplus/ency/article/002215.htm Breathing shallow Web site: http://www.nlm.nih.gov/medlineplus/ency/article/000007.htm Breathing slow and labored Web site: http://www.nlm.nih.gov/medlineplus/ency/article/000007.htm Intravenous Web site: http://www.nlm.nih.gov/medlineplus/ency/article/002383.htm Respiratory Web site: http://www.nlm.nih.gov/medlineplus/ency/article/002290.htm Stopped breathing (sometimes fatal within 2-4 hours) Web site: http://www.nlm.nih.gov/medlineplus/ency/article/000007.htm


Online Dictionary Directories The following are additional online directories compiled by the National Library of Medicine, including a number of specialized medical dictionaries and glossaries: ·

Medical Dictionaries: Medical & Biological (World Health Organization): http://www.who.int/hlt/virtuallibrary/English/diction.htm#Medical

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MEL-Michigan Electronic Library List of Online Health and Medical Dictionaries (Michigan Electronic Library): http://mel.lib.mi.us/health/health-dictionaries.html

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Patient Education: Glossaries (DMOZ Open Directory Project): http://dmoz.org/Health/Education/Patient_Education/Glossaries/

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Web of Online Dictionaries (Bucknell University): http://www.yourdictionary.com/diction5.html#medicine

Glossary 201

HEROIN DEPENDENCE GLOSSARY The following is a complete glossary of terms used in this sourcebook. The definitions are derived from official public sources including the National Institutes of Health [NIH] and the European Union [EU]. After this glossary, we list a number of additional hardbound and electronic glossaries and dictionaries that you may wish to consult. Abortion: 1. the premature expulsion from the uterus of the products of conception - of the embryo, or of a nonviable fetus. The four classic symptoms, usually present in each type of abortion, are uterine contractions, uterine haemorrhage, softening and dilatation of the cervix, and presentation or expulsion of all or part of the products of conception. 2. premature stoppage of a natural or a pathological process. [EU] ACTH: Adrenocorticotropic hormone. [EU] Agar: A complex sulfated polymer of galactose units, extracted from Gelidium cartilagineum, Gracilaria confervoides, and related red algae. It is used as a gel in the preparation of solid culture media for microorganisms, as a bulk laxative, in making emulsions, and as a supporting medium for immunodiffusion and immunoelectrophoresis. [NIH] Amphetamine: A powerful central nervous system stimulant and sympathomimetic. Amphetamine has multiple mechanisms of action including blocking uptake of adrenergics and dopamine, stimulation of release of monamines, and inhibiting monoamine oxidase. Amphetamine is also a drug of abuse and a psychotomimetic. The l- and the d,l-forms are included here. The l-form has less central nervous system activity but stronger cardiovascular effects. The d-form is DEXTROAMPHETAMINE. [NIH]

Analgesics: A group of medications that reduce pain. [NIH] Analog: A chemical compound that is similar to another drug in its effects but differs slightly in its chemical structure. [NIH] Anatomical: Pertaining to anatomy, or to the structure of the organism. [EU] Anesthesia: A state characterized by loss of feeling or sensation. This depression of nerve function is usually the result of pharmacologic action and is induced to allow performance of surgery or other painful procedures. [NIH]

Antidepressants: A group of drugs used in treating depressive disorders. [NIH]

Antidote: A remedy for counteracting a poison. [EU] Antiviral: Destroying viruses or suppressing their replication. [EU]


Anxiety: The unpleasant emotional state consisting of psychophysiological responses to anticipation of unreal or imagined danger, ostensibly resulting from unrecognized intrapsychic conflict. Physiological concomitants include increased heart rate, altered respiration rate, sweating, trembling, weakness, and fatigue; psychological concomitants include feelings of impending danger, powerlessness, apprehension, and tension. [EU] Autonomic: Self-controlling; functionally independent. [EU] Barbiturate: A type of central nervous system (CNS) depressant often prescribed to promote sleep. [NIH] Benign: Not malignant; not recurrent; favourable for recovery. [EU] Benzodiazepine: A type of CNS depressant prescribed to relieve anxiety; among the most widely prescribed medications, including Valium and Librium. [NIH] Bioavailability: The degree to which a drug or other substance becomes available to the target tissue after administration. [EU] Biochemical: Relating to biochemistry; characterized by, produced by, or involving chemical reactions in living organisms. [EU] Buprenorphine: A mixed opiate agonist/antagonist medication for the treatment of heroin addiction. [NIH] Bupropion: A unicyclic, aminoketone antidepressant. The mechanism of its therapeutic actions is not well understood, but it does appear to block dopamine uptake. The hydrochloride is available as an aid to smoking cessation treatment. [NIH] Butorphanol: A synthetic morphinan analgesic with narcotic antagonist action. It is used in the management of severe pain. [NIH] Carbohydrate: An aldehyde or ketone derivative of a polyhydric alcohol, particularly of the pentahydric and hexahydric alcohols. They are so named because the hydrogen and oxygen are usually in the proportion to form water, (CH2O)n. The most important carbohydrates are the starches, sugars, celluloses, and gums. They are classified into mono-, di-, tri-, poly- and heterosaccharides. [EU] Cellulitis: An acute, diffuse, and suppurative inflammation of loose connective tissue, particularly the deep subcutaneous tissues, and sometimes muscle, which is most commonly seen as a result of infection of a wound, ulcer, or other skin lesions. [NIH] Cerebrospinal: Pertaining to the brain and spinal cord. [EU] Cholesterol: The principal sterol of all higher animals, distributed in body tissues, especially the brain and spinal cord, and in animal fats and oils. [NIH] Chromosomal: Pertaining to chromosomes. [EU]

Glossary 203

Chronic: Persisting over a long period of time. [EU] Cocaine: An alkaloid ester extracted from the leaves of plants including coca. It is a local anesthetic and vasoconstrictor and is clinically used for that purpose, particularly in the eye, ear, nose, and throat. It also has powerful central nervous system effects similar to the amphetamines and is a drug of abuse. Cocaine, like amphetamines, acts by multiple mechanisms on brain catecholaminergic neurons; the mechanism of its reinforcing effects is thought to involve inhibition of dopamine uptake. [NIH] Comorbidity: The presence of co-existing or additional diseases with reference to an initial diagnosis or with reference to the index condition that is the subject of study. Comorbidity may affect the ability of affected individuals to function and also their survival; it may be used as a prognostic indicator for length of hospital stay, cost factors, and outcome or survival. [NIH] Condoms: A sheath that is worn over the penis during sexual behavior in order to prevent pregnancy or spread of sexually transmitted disease. [NIH] Constipation: Infrequent or difficult evacuation of the faeces. [EU] Cortex: The outer layer of an organ or other body structure, as distinguished from the internal substance. [EU] Cortical: Pertaining to or of the nature of a cortex or bark. [EU] Crack: Short term for a smokable form of cocaine. [NIH] Craving: A powerful, often uncontrollable desire for drugs. [NIH] Cues: Signals for an action; that specific portion of a perceptual field or pattern of stimuli to which a subject has learned to respond. [NIH] Degenerative: Undergoing degeneration : tending to degenerate; having the character of or involving degeneration; causing or tending to cause degeneration. [EU] Dementia: A condition of deteriorated mentality. [NIH] Deprivation: Loss or absence of parts, organs, powers, or things that are needed. [EU] Detoxification: A process of allowing the body to rid itself of a drug while managing the symptoms of withdrawal; often the first step in a drug treatment program. [NIH] Diarrhea: Passage of excessively liquid or excessively frequent stools. [NIH] Electroacupuncture: A form of acupuncture using low frequency electrically stimulated needles to produce analgesia and anesthesia and to treat disease. [NIH]

Endocarditis: Exudative and proliferative inflammatory alterations of the endocardium, characterized by the presence of vegetations on the surface of


the endocardium or in the endocardium itself, and most commonly involving a heart valve, but sometimes affecting the inner lining of the cardiac chambers or the endocardium elsewhere. It may occur as a primary disorder or as a complication of or in association with another disease. [EU] Endogenous: Developing or originating within the organisms or arising from causes within the organism. [EU] Epidemic: Occurring suddenly in numbers clearly in excess of normal expectancy; said especially of infectious diseases but applied also to any disease, injury, or other health-related event occurring in such outbreaks. [EU] Epidemiological: Relating to, or involving epidemiology. [EU] Euphoria: An exaggerated feeling of physical and mental well-being, especially when not justified by external reality. Euphoria may be induced by drugs such as opioids, amphetamines, and alcohol and is also a feature of mania. [EU] Excitation: An act of irritation or stimulation or of responding to a stimulus; the addition of energy, as the excitation of a molecule by absorption of photons. [EU] Extraction: The process or act of pulling or drawing out. [EU] Fatal: Causing death, deadly; mortal; lethal. [EU] Fentanyl: A medically useful opioid analog that is 50 times more potent than heroin. [NIH] Fluoxetine: The first highly specific serotonin uptake inhibitor. It is used as an antidepressant and often has a more acceptable side-effects profile than traditional antidepressants. [NIH] Flushing: A transient reddening of the face that may be due to fever, certain drugs, exertion, stress, or a disease process. [NIH] GABA: The most common inhibitory neurotransmitter in the central nervous system. [NIH] Genotype: The genetic constitution of the individual; the characterization of the genes. [NIH] Glucose: D-glucose, a monosaccharide (hexose), C6H12O6, also known as dextrose (q.v.), found in certain foodstuffs, especially fruits, and in the normal blood of all animals. It is the end product of carbohydrate metabolism and is the chief source of energy for living organisms, its utilization being controlled by insulin. Excess glucose is converted to glycogen and stored in the liver and muscles for use as needed and, beyond that, is converted to fat and stored as adipose tissue. Glucose appears in the urine in diabetes mellitus. [EU] Gynecology: A medical-surgical specialty concerned with the physiology

Glossary 205

and disorders primarily of the female genital tract, as well as female endocrinology and reproductive physiology. [NIH] Hepatitis: Inflammation of the liver. [EU] Homicide: The killing of one person by another. [NIH] Hormonal: Pertaining to or of the nature of a hormone. [EU] Hormone: A chemical substance formed in glands in the body and carried in the blood to organs and tissues, where it influences function, structure, and behavior. [NIH] Hypertension: Persistently high arterial blood pressure. Various criteria for its threshold have been suggested, ranging from 140 mm. Hg systolic and 90 mm. Hg diastolic to as high as 200 mm. Hg systolic and 110 mm. Hg diastolic. Hypertension may have no known cause (essential or idiopathic h.) or be associated with other primary diseases (secondary h.). [EU] Hyperthermia: Abnormally high body temperature, especially that induced for therapeutic purposes. [EU] Hypotensive: Characterized by or causing diminished tension or pressure, as abnormally low blood pressure. [EU] Incarceration: Abnormal retention or confinement of a body part; specifically : a constriction of the neck of a hernial sac so that the hernial contents become irreducible. [EU] Infusion: The therapeutic introduction of a fluid other than blood, as saline solution, solution, into a vein. [EU] Inhalation: The drawing of air or other substances into the lungs. [EU] Insomnia: Inability to sleep; abnormal wakefulness. [EU] Institutionalization: The caring for individuals in institutions and their adaptation to routines characteristic of the institutional environment, and/or their loss of adaptation to life outside the institution. [NIH] Intestinal: Pertaining to the intestine. [EU] Intramuscular: Within the substance of a muscle. [EU] Intravenous: Within a vein or veins. [EU] Iodine: A nonmetallic element of the halogen group that is represented by the atomic symbol I, atomic number 53, and atomic weight of 126.90. It is a nutritionally essential element, especially important in thyroid hormone synthesis. In solution, it has anti-infective properties and is used topically. [NIH]

LAAM: An approved medication for the treatment of opioid addiction, taken 3 to 4 times a week. [NIH] Leptin:

A 16-kD peptide hormone secreted from white adipocytes and


implicated in the regulation of food intake and energy balance. Leptin provides the key afferent signal from fat cells in the feedback system that controls body fat stores. [NIH] LH: A small glycoprotein hormone secreted by the anterior pituitary. LH plays an important role in controlling ovulation and in controlling secretion of hormones by the ovaries and testes. [NIH] Localization: 1. the determination of the site or place of any process or lesion. 2. restriction to a circumscribed or limited area. 3. prelocalization. [EU] Locomotion: Movement or the ability to move from one place or another. It can refer to humans, vertebrate or invertebrate animals, and microorganisms. [NIH] Lumbar: Pertaining to the loins, the part of the back between the thorax and the pelvis. [EU] Memantine: Amantadine derivative that has some dopaminergic effects. It has been proposed as an antiparkinson agent. [NIH] Meperidine: A medically approved opioid available under various brand names (e.g., Demerol). [NIH] Methadone: A long-acting synthetic medication shown to be effective in treating heroin addiction. [NIH] Methamphetamine: A central nervous system stimulant and sympathomimetic with actions and uses similar to dextroamphetamine. The smokable form is a drug of abuse and is referred to as crank, crystal, crystal meth, ice, and speed. [NIH] Microdialysis: A technique for measuring extracellular concentrations of substances in tissues, usually in vivo, by means of a small probe equipped with a semipermeable membrane. Substances may also be introduced into the extracellular space through the membrane. [NIH] Molecular: Of, pertaining to, or composed of molecules : a very small mass of matter. [EU] Monocytes: Large, phagocytic mononuclear leukocytes produced in the vertebrate bone marrow and released into the blood; contain a large, oval or somewhat indented nucleus surrounded by voluminous cytoplasm and numerous organelles. [NIH] Morphine: The principal alkaloid in opium and the prototype opiate analgesic and narcotic. Morphine has widespread effects in the central nervous system and on smooth muscle. [NIH] Mucosa: A mucous membrane, or tunica mucosa. [EU] Myopathy: Any disease of a muscle. [EU] Naloxone: A specific opiate antagonist that has no agonist activity. It is a

Glossary 207

competitive antagonist at mu, delta, and kappa opioid receptors. [NIH] Naltrexone: Derivative of noroxymorphone that is the N-cyclopropylmethyl congener of Naloxone. It is a narcotic antagonist that is effective orally, longer lasting and more potent than naloxone, and has been proposed for the treatment of heroin addiction. The FDA has approved naltrexone for the treatment of alcohol dependence. [NIH] Narcotic: 1. pertaining to or producing narcosis. 2. an agent that produces insensibility or stupor, applied especially to the opioids, i.e. to any natural or synthetic drug that has morphine-like actions. [EU] Nausea: An unpleasant sensation, vaguely referred to the epigastrium and abdomen, and often culminating in vomiting. [EU] Neonatal: Pertaining to the first four weeks after birth. [EU] Neural: 1. pertaining to a nerve or to the nerves. 2. situated in the region of the spinal axis, as the neutral arch. [EU] Neuroleptic: A term coined to refer to the effects on cognition and behaviour of antipsychotic drugs, which produce a state of apathy, lack of initiative, and limited range of emotion and in psychotic patients cause a reduction in confusion and agitation and normalization of psychomotor activity. [EU] Neurology: A medical specialty concerned with the study of the structures, functions, and diseases of the nervous system. [NIH] Neuronal: Pertaining to a neuron or neurons (= conducting cells of the nervous system). [EU] Niacin: Water-soluble vitamin of the B complex occurring in various animal and plant tissues. Required by the body for the formation of coenzymes NAD and NADP. Has pellagra-curative, vasodilating, and antilipemic properties. [NIH] Nicotine: An alkaloid derived from the tobacco plant that is responsible for smoking's psychoactive and addictive effects; is toxic at high doses but can be safe and effective as medicine at lower doses. [NIH] NMDA: N-methyl-D-aspartate, a chemical compound that reacts with glutamate receptors on nerve cells. [NIH] Obstetrics: A medical-surgical specialty concerned with management and care of women during pregnancy, parturition, and the puerperium. [NIH] Opiate: A remedy containing or derived from opium; also any drug that induces sleep. [EU] Opioids: Controlled drugs or narcotics most often prescribed for the management of pain; natural or synthetic chemicals based on opium's active component - morphine - that work by mimicking the actions of pain-


relieving chemicals produced in the body. [NIH] Opium: The air-dried exudate from the unripe seed capsule of the opium poppy, Papaver somniferum, or its variant, P. album. It contains a number of alkaloids, but only a few - morphine, codeine, and papaverine - have clinical significance. Opium has been used as an analgesic, antitussive, antidiarrheal, and antispasmodic. [NIH] Overdose: 1. to administer an excessive dose. 2. an excessive dose. [EU] Parity: The number of offspring a female has borne. It is contrasted with gravidity, which refers to the number of pregnancies, regardless of outcome. [NIH]

Pathogen: Any disease-producing microorganism. [EU] Pediatrics: A medical specialty concerned with maintaining health and providing medical care to children from birth to adolescence. [NIH] Pharmacokinetics: The pattern of absorption, distribution, and excretion of a drug over time. [NIH] Pharmacologic: Pertaining to pharmacology or to the properties and reactions of drugs. [EU] Pneumonia: Inflammation of the lungs with consolidation. [EU] Potassium: An element that is in the alkali group of metals. It has an atomic symbol K, atomic number 19, and atomic weight 39.10. It is the chief cation in the intracellular fluid of muscle and other cells. Potassium ion is a strong electrolyte and it plays a significant role in the regulation of fluid volume and maintenance of the water-electrolyte balance. [NIH] Precursor: Something that precedes. In biological processes, a substance from which another, usually more active or mature substance is formed. In clinical medicine, a sign or symptom that heralds another. [EU] Predisposition: A latent susceptibility to disease which may be activated under certain conditions, as by stress. [EU] Prenatal: Existing or occurring before birth, with reference to the fetus. [EU] Prevalence: The total number of cases of a given disease in a specified population at a designated time. It is differentiated from INCIDENCE, which refers to the number of new cases in the population at a given time. [NIH] Prolactin: Pituitary lactogenic hormone. A polypeptide hormone with a molecular weight of about 23,000. It is essential in the induction of lactation in mammals at parturition and is synergistic with estrogen. The hormone also brings about the release of progesterone from lutein cells, which renders the uterine mucosa suited for the embedding of the ovum should fertilization occur. [NIH] Psychiatric: Pertaining to or within the purview of psychiatry. [EU]

Glossary 209

Psychiatry: The medical science that deals with the origin, diagnosis, prevention, and treatment of mental disorders. [NIH] Psychology: The science dealing with the study of mental processes and behavior in man and animals. [NIH] Psychopathology: The study of significant causes and processes in the development of mental illness. [NIH] Psychotherapy: A generic term for the treatment of mental illness or emotional disturbances primarily by verbal or nonverbal communication. [NIH]

Pulmonary: Pertaining to the lungs. [EU] Receptor: 1. a molecular structure within a cell or on the surface characterized by (1) selective binding of a specific substance and (2) a specific physiologic effect that accompanies the binding, e.g., cell-surface receptors for peptide hormones, neurotransmitters, antigens, complement fragments, and immunoglobulins and cytoplasmic receptors for steroid hormones. 2. a sensory nerve terminal that responds to stimuli of various kinds. [EU] Respiratory: Pertaining to respiration. [EU] Riboflavin: Nutritional factor found in milk, eggs, malted barley, liver, kidney, heart, and leafy vegetables. The richest natural source is yeast. It occurs in the free form only in the retina of the eye, in whey, and in urine; its principal forms in tissues and cells are as FMN and FAD. [NIH] Saliva: The clear, viscous fluid secreted by the salivary glands and mucous glands of the mouth. It contains mucins, water, organic salts, and ptylin. [NIH] Sclerosis: A induration, or hardening; especially hardening of a part from inflammation and in diseases of the interstitial substance. The term is used chiefly for such a hardening of the nervous system due to hyperplasia of the connective tissue or to designate hardening of the blood vessels. [EU] Sedative: 1. allaying activity and excitement. 2. an agent that allays excitement. [EU] Selenium: An element with the atomic symbol Se, atomic number 34, and atomic weight 78.96. It is an essential micronutrient for mammals and other animals but is toxic in large amounts. Selenium protects intracellular structures against oxidative damage. It is an essential component of glutathione peroxidase. [NIH] Sensitization: 1. administration of antigen to induce a primary immune response; priming; immunization. 2. exposure to allergen that results in the development of hypersensitivity. 3. the coating of erythrocytes with antibody so that they are subject to lysis by complement in the presence of homologous antigen, the first stage of a complement fixation test. [EU]


Serotonin: A neurotransmitter that causes a very broad range of effects on perception, movement, and the emotions by modulating the actions of other neurotransmitters in most parts of the brain. [NIH] Stabilization: The creation of a stable state. [EU] Stimulant: 1. producing stimulation; especially producing stimulation by causing tension on muscle fibre through the nervous tissue. 2. an agent or remedy that produces stimulation. [EU] Strychnine: An alkaloid found in the seeds of nux vomica. It is a competitive antagonist at glycine receptors and thus a convulsant. It has been used as an analeptic, in the treatment of nonketotic hyperglycinemia and sleep apnea, and as a rat poison. [NIH] Sublingual: Located beneath the tongue. [EU] Substrate: A substance upon which an enzyme acts. [EU] Systemic: Pertaining to or affecting the body as a whole. [EU] Thermoregulation: Heat regulation. [EU] Thrombophlebitis: formation. [EU]

Inflammation of a vein associated with thrombus

Thyroxine: An amino acid of the thyroid gland which exerts a stimulating effect on thyroid metabolism. [NIH] Tolerance: A condition in which higher doses of a drug are required to produce the same effect as during initial use; often is associated with physical dependence. [NIH] Tomography: The recording of internal body images at a predetermined plane by means of the tomograph; called also body section roentgenography. [EU]

Toxicity: The quality of being poisonous, especially the degree of virulence of a toxic microbe or of a poison. [EU] Toxicology: The science concerned with the detection, chemical composition, and pharmacologic action of toxic substances or poisons and the treatment and prevention of toxic manifestations. [NIH] Toxicomania: Addiction to a drug (as opium or cocaine). [EU] Transdermal: Entering through the dermis, or skin, as in administration of a drug applied to the skin in ointment or patch form. [EU] Tremor: An involuntary trembling or quivering. [EU] Tuberculosis: Any of the infectious diseases of man and other animals caused by species of mycobacterium. [NIH] Urinalysis: Examination of urine by chemical, physical, or microscopic means. Routine urinalysis usually includes performing chemical screening

Glossary 211

tests, determining specific gravity, observing any unusual color or odor, screening for bacteriuria, and examining the sediment microscopically. [NIH] Veins: The vessels carrying blood toward the heart. [NIH] Ventral: 1. pertaining to the belly or to any venter. 2. denoting a position more toward the belly surface than some other object of reference; same as anterior in human anatomy. [EU] Viruses: Minute infectious agents whose genomes are composed of DNA or RNA, but not both. They are characterized by a lack of independent metabolism and the inability to replicate outside living host cells. [NIH] Withdrawal: A variety of symptoms that occur after chronic use of some drugs is reduced or stopped. [NIH]

General Dictionaries and Glossaries While the above glossary is essentially complete, the dictionaries listed here cover virtually all aspects of medicine, from basic words and phrases to more advanced terms (sorted alphabetically by title; hyperlinks provide rankings, information and reviews at Amazon.com): ·

Dictionary of Medical Acronymns & Abbreviations by Stanley Jablonski (Editor), Paperback, 4th edition (2001), Lippincott Williams & Wilkins Publishers, ISBN: 1560534605, http://www.amazon.com/exec/obidos/ASIN/1560534605/icongroupinterna

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Dictionary of Medical Terms : For the Nonmedical Person (Dictionary of Medical Terms for the Nonmedical Person, Ed 4) by Mikel A. Rothenberg, M.D, et al, Paperback - 544 pages, 4th edition (2000), Barrons Educational Series, ISBN: 0764112015, http://www.amazon.com/exec/obidos/ASIN/0764112015/icongroupinterna

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A Dictionary of the History of Medicine by A. Sebastian, CD-Rom edition (2001), CRC Press-Parthenon Publishers, ISBN: 185070368X, http://www.amazon.com/exec/obidos/ASIN/185070368X/icongroupinterna

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Dorland's Illustrated Medical Dictionary (Standard Version) by Dorland, et al, Hardcover - 2088 pages, 29th edition (2000), W B Saunders Co, ISBN: 0721662544, http://www.amazon.com/exec/obidos/ASIN/0721662544/icongroupinterna

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Dorland's Electronic Medical Dictionary by Dorland, et al, Software, 29th Book & CD-Rom edition (2000), Harcourt Health Sciences, ISBN: 0721694934, http://www.amazon.com/exec/obidos/ASIN/0721694934/icongroupinterna


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Dorland's Pocket Medical Dictionary (Dorland's Pocket Medical Dictionary, 26th Ed) Hardcover - 912 pages, 26th edition (2001), W B Saunders Co, ISBN: 0721682812, http://www.amazon.com/exec/obidos/ASIN/0721682812/icongroupinterna

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Melloni's Illustrated Medical Dictionary (Melloni's Illustrated Medical Dictionary, 4th Ed) by Melloni, Hardcover, 4th edition (2001), CRC PressParthenon Publishers, ISBN: 85070094X, http://www.amazon.com/exec/obidos/ASIN/85070094X/icongroupinterna

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Stedman's Electronic Medical Dictionary Version 5.0 (CD-ROM for Windows and Macintosh, Individual) by Stedmans, CD-ROM edition (2000), Lippincott Williams & Wilkins Publishers, ISBN: 0781726328, http://www.amazon.com/exec/obidos/ASIN/0781726328/icongroupinterna

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Stedman's Medical Dictionary by Thomas Lathrop Stedman, Hardcover 2098 pages, 27th edition (2000), Lippincott, Williams & Wilkins, ISBN: 068340007X, http://www.amazon.com/exec/obidos/ASIN/068340007X/icongroupinterna

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Tabers Cyclopedic Medical Dictionary (Thumb Index) by Donald Venes (Editor), et al, Hardcover - 2439 pages, 19th edition (2001), F A Davis Co, ISBN: 0803606540, http://www.amazon.com/exec/obidos/ASIN/0803606540/icongroupinterna

Index 213

INDEX A Abortion .......................14, 17, 21, 46, 203 Adverse .........................................30, 173 Analog ...........................................48, 206 Anatomical.......................................31, 41 Anesthesia...............................83, 92, 205 Antidepressants...................157, 172, 206 Antiviral ..................................................19 Anxiety.....................32, 47, 108, 172, 204 Autonomic..............................................36 B Barbiturate .............................................23 Benign ...................................................17 Biochemical .........................................140 Buprenorphine ..... 18, 19, 35, 37, 64, 66, 67, 68, 69, 70, 71, 72, 83, 84, 86, 87, 88, 153, 154 Bupropion ....................................168, 172 Butorphanol ...........................................88 C Carbohydrate.........................48, 150, 206 Cardiac ..........................................48, 206 Cellulitis .................................................22 Cerebral.................................................32 Cerebrospinal ......................................139 Cholesterol ..................................148, 150 Chromosomal ........................................82 Chronic ...11, 16, 17, 30, 51, 89, 154, 170, 171, 172, 173, 213 Cocaine ....... 34, 37, 56, 72, 96, 97, 103, 106, 139, 153, 154, 158, 175, 177, 181, 184, 185, 186, 189, 190, 191, 192, 205, 212 Comorbidity ...........................................86 Condoms .......................................44, 114 Cortex ......................................31, 91, 205 Cortical ..................................................88 Craving .......11, 16, 19, 22, 33, 38, 41, 70, 108, 170, 175, 179 Cues ....................................................173 D Degenerative .......................................149 Deprivation ..........................................155 Detoxification ....18, 30, 35, 36, 41, 83, 87, 88, 139, 141, 142, 144, 153, 169, 179, 182, 189 Diarrhea...................................16, 22, 148 E Electroacupuncture..............................141 Endocarditis...........................................34 Endogenous ..........................................85

Epidemic ......................... 28, 86, 108, 181 Epidemiological............................... 33, 41 Euphoria.................... 13, 19, 22, 175, 180 Excitation ................................ 32, 48, 206 Extraction ............................................ 155 F Fatal .................. 16, 21, 22, 114, 182, 201 Fentanyl ................................................ 20 Fluoxetine ........................................... 153 Flushing .......................................... 15, 22 G Glucose................................... 32, 48, 206 Gynecology ........................................... 39 H Hepatitis ..... 15, 17, 21, 28, 29, 32, 35, 37, 169, 177 Hormonal .............................................. 89 Hormone ...... 91, 92, 149, 158, 203, 207, 208, 210 Hypertension....................................... 173 Hyperthermia .............................. 141, 142 Hypotensive .......................................... 88 I Incarceration ....................... 176, 182, 183 Infusion ................................................. 40 Inhalation .............................................. 15 Insomnia ......................................... 16, 22 Institutionalization ............................... 187 Intramuscular ........................................ 13 Intravenous ..... 13, 28, 32, 37, 66, 68, 72, 189 L Localization ........................................... 82 Locomotion ......................................... 143 M Memantine ...................................... 87, 88 Meperidine ............................................ 20 Methamphetamine .............................. 185 Microdialysis ......................................... 89 Molecular ... 16, 33, 50, 92, 112, 116, 117, 210, 211 Monocytes........................................... 154 Morphine .... 12, 15, 19, 21, 23, 27, 49, 66, 85, 155, 209 Mucosa ..................... 32, 49, 92, 208, 210 Myopathy ............................................ 154 N Naloxone.... 23, 32, 49, 66, 67, 68, 70, 71, 85, 87, 141, 209 Naltrexone..... 19, 23, 29, 36, 49, 64, 83, 86, 87, 153, 154, 155, 172, 185, 209


Narcotic 18, 20, 27, 28, 29, 44, 49, 89, 91, 102, 104, 140, 204, 208, 209 Nausea ............................................15, 32 Neural ..................................................149 Neuronal ..........................................32, 33 Niacin...................................................148 Nicotine................168, 172, 182, 188, 189 O Obstetrics ..............................................39 Opioids ....31, 32, 33, 36, 48, 49, 206, 209 Opium ...49, 108, 109, 158, 208, 209, 210, 212 P Parity .....................................................42 Pediatrics...............................................39 Pharmacologic......20, 36, 37, 91, 93, 203, 212 Pneumonia ......................................17, 22 Potassium............................................150 Precursor .....................................169, 182 Predisposition ........................................31 Prenatal .................................................35 Prevalence.............24, 25, 28, 41, 86, 103 Prisons...................................................28 Prolactin...............................................142 Psychiatric ...... 30, 36, 86, 175, 185, 186, 192 Psychiatry ................................26, 50, 210 Psychology ............................................26 Psychopathology .................................102 Psychotherapy.........37, 83, 168, 171, 185 Pulmonary .............................................32 R Receptor ..............................31, 32, 84, 87

Riboflavin ............................................ 148 S Saliva .................................................... 32 Sclerosis ....................................... 32, 118 Selenium ............................................. 150 Sensitization ....................................... 143 Serotonin............................... 89, 157, 206 Stabilization........................................... 89 Stimulant ............... 46, 184, 196, 203, 208 Strychnine ............................................. 12 Surgical ..................... 20, 48, 49, 206, 209 T Thermoregulation................................ 148 Thrombophlebitis .................................. 34 Thyroxine ............................................ 149 Tolerance ................ 16, 22, 30, 32, 44, 85 Tomography.......................................... 32 Toxicity................................................ 141 Toxicology..................................... 86, 113 Transdermal........................................ 189 Tremor ................................................ 118 Tuberculosis.............. 17, 28, 35, 169, 177 U Urinalysis ............ 169, 187, 190, 197, 212 V Veins ............... 15, 17, 21, 22, 32, 49, 207 Ventral............................................. 31, 89 Viruses .............................. 17, 28, 47, 203 W Withdrawal .... 16, 18, 19, 22, 27, 30, 32, 35, 36, 38, 47, 66, 70, 83, 84, 85, 87, 88, 140, 142, 143, 155, 169, 179, 182, 189, 205

Index 215


Index 217


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The Official Patient's Sourcebook on Inhalants Dependence: A Revised and Updated Directory for the Internet Age

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