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Clinical Crossroads | Clinician's Corner

A 50-Year-Old Woman Addicted to Heroin:  Review of Treatment of Heroin Addiction

Charles P. O’Brien, MD, PhD, Discussant
JAMA. 2008;300(3):314-321. doi:10.1001/jama.300.1.jrr80005.
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Heroin addiction is a complicated medical and psychiatric issue, with well-established as well as newer modes of treatment. The case of Ms W, a 50-year-old woman with a long history of opiate addiction who has been treated successfully with methadone for 9 years and who now would like to consider newer alternatives, illustrates the complex issues of heroin addiction. The treatment of heroin addiction as a chronic disease is reviewed, including social, medical, and cultural issues and pharmacologic treatment with methadone and the more experimental medication options of buprenorphine and naltrexone.

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Stigma of Methadone Maintenance as a Precipitator of Relapse to Active Heroin Use
Posted on July 1, 2008
Douglas C. Meyer, M.Ed
none
Conflict of Interest: None Declared
Ms M gives us the answer we need in her own perspective statement. She states that people don't view her as "clean" as long as she is on the program (methadone maintenance). She states she wants to be a good role model to her children and grandchildren, and the implication is that she feels she can't be a good role model while on methadone maintenance. Her medical history indicates just the opposite. She has, while in methadone treatment, met her family responsibilities. The fact that she attends the clinic once weekly and is trusted with take home medication indicates her urine monitoring results have been satisfactory. That there is a stigma attached to methadone maintenance treatment is an intuitive fact. The stigma is enhanced by the system of methadone administration in the U.S. where patients must be medicated at approved treatment centers as opposed to the system in Canada where patients are medicated at community pharmacies and attend the clinic only for their doctors appointments, etc. (1,2) The system in Canada minimizes the time spent associating with other patients, minimizes the problem of addicts congregating near clinics, and makes the patient's self-image much more positive. Waiting in a medication line with other addicts with a wide range of time in treatment to be medicated by a nurse who must treat every patient with suspicion is not likely to result in a positive self-image.
Another fact to consider is the relatively high dose of 108 mg/day which Mrs M needs to be comfortable. Frankly, I would consider the possibility of illegal methadone diversion which can result from an economic incentive, especially in low income patients. Ms M may be sincere in her desire to put such criminal activity behind her and rid herself of the stigma of methadone maintenance. Contemplation of instituting a detox of this patient could only be justified by a professional who buys into a societal view of methadone maintenance as negative. Long-term methadone maintenance in a 50 year old patient who has a long history of relapse is the only viable alternative. Ms M should be counseled to minimize her feelings of stigma. (Often methadone maintenance patients do better with A.A. as opposed to N.A. as a self-help group because of the issue of stigma.)(3) Her positive accomplishments, including those with regard to her family responsibilities, should be pointed out often to her. The consequences of another relapse should be discussed. She should be monitored closely for any indication that she is, on any level, trying to use stigma as an excuse to relapse or set herself up to relapse. It could be pointed out to her that methadone maintenance may have saved her from HIV exposure.(4) Ms M should also be told in a kindly and non-threatening manner that if she has become involved in methadone diversion steps can be taken to solve the problem with no harm to her. Finally, Ms M should be told that the realistic way to achieve a drug-free life, if she decides that is really what she wants, is via a long detox (max reduction of 2mg/month) followed by buprenorphine treatment.(5)
No relevant financial interests.
References
1. Fischer, B. Prescriptions, Power, and Politics: The Turbulent History of Methadone Maintenance in Canada, Journal of Public Health Policy.2000;21(2):187-210.
2. Ontario Methadone Maintenance Treatment Practices Taskforce, www.methadonetaskforce.com/background.asp. Accessed July 14, 2008.
3. Glickman, L. Pathways to Recovery, Adapting 12-step Recovery to Methadone Treatment.2005:77-90. DOI: 10.1300/J126v02n04_08
4. Zaric GS, Brandeau ML, Barnett PG. Methadone maintenance and HIV prevention: a cost-effectiveness analysis. Management Science.2000;46(8):1013-1031.
5. Rettig, R. Federal Regulation of Methadone Treatment, Committee on Methadone Regulations, Institute of Medicine, National Archives Press.1995:205.
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