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Bridging the Gap Between Practice and Research: Forging Partnerships with Community-Based Drug and Alcohol Treatment (1998)

Chapter: Appendix F: National Institute of Health Consensus Development Statement on Effective Medical Treatment of Heroin Addiction

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Suggested Citation:"Appendix F: National Institute of Health Consensus Development Statement on Effective Medical Treatment of Heroin Addiction." Institute of Medicine. 1998. Bridging the Gap Between Practice and Research: Forging Partnerships with Community-Based Drug and Alcohol Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6169.
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F

National Institutes of Health Consensus Development Statement on Effective Medical Treatment of Heroin Addiction

NIH Consensus Statements are prepared by a nonadvocate, non-Federal panel of experts, based on (1) presentations by investigators working in areas relevant to the consensus questions during a 2-day public session; (2) questions and statements from conference attendees during open discussion periods that are part of the public session; and (3) closed deliberations by the panel during the remainder of the second day and morning of the third. This statement is an independent report of the consensus panel and is not a policy statement of the NIH or the Federal Government.

ABSTRACT

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

SOURCE: National Institutes of Health. 1997. NIH Consensus Development Statement: Effective Medical Treatment of Heroin Addiction. November 17-19, 1997 [WWW Document]. URL http://odp.od.nih.gov/consensus/statements/cdc/108/108_stmt.html (Accessed March 27, 1998).

This statement will be published as: Effective Medical Treatment of Opiate Addiction. NIH Consensus Statement 1997 November 17-19;15(6): in press. For making bibliographic reference to consensus statement No. 108 in the electronic form displayed here, it is recommended that the following format be used: NIH Consensus Statement Online 1997 November 17-19 [cited year, month, day]; 15(6): in press.

Suggested Citation:"Appendix F: National Institute of Health Consensus Development Statement on Effective Medical Treatment of Heroin Addiction." Institute of Medicine. 1998. Bridging the Gap Between Practice and Research: Forging Partnerships with Community-Based Drug and Alcohol Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6169.
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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.

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 long-acting opiate agonist treatment programs should be reduced, and coverage for these programs should be a required benefit in public and private insurance programs.

INTRODUCTION

In the United States, prior to 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

Suggested Citation:"Appendix F: National Institute of Health Consensus Development Statement on Effective Medical Treatment of Heroin Addiction." Institute of Medicine. 1998. Bridging the Gap Between Practice and Research: Forging Partnerships with Community-Based Drug and Alcohol Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6169.
×

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 has increased from 36,000 to 76,000, and the annual number of opiate-related deaths has 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 that 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

Suggested Citation:"Appendix F: National Institute of Health Consensus Development Statement on Effective Medical Treatment of Heroin Addiction." Institute of Medicine. 1998. Bridging the Gap Between Practice and Research: Forging Partnerships with Community-Based Drug and Alcohol Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6169.
×

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 consensus development conference was primarily on methadone maintenance treatment (MMT). MMT is effective in reducing illicit opiate drug use, in crime reduction, 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 a moral flaw. They also regard MMT as an ineffective narcotic substitution and believe that a drug-free 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 crime, and gainful employment can be achieved in 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:

Suggested Citation:"Appendix F: National Institute of Health Consensus Development Statement on Effective Medical Treatment of Heroin Addiction." Institute of Medicine. 1998. Bridging the Gap Between Practice and Research: Forging Partnerships with Community-Based Drug and Alcohol Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6169.
×
  • What is the scientific evidence to support conceptualization of opiate addiction as a medical disorder including natural history, genetics and risk factors, 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 U.S. including perceptions and adverse consequences of opiate agonist use, legal, regulatory, financial and programmatic barriers?
  • What are the future research areas and recommendations for improving opiate agonist treatment and improving access?

The primary sponsors of this meeting were the National Institute on Drug Abuse and the NIH Office of Medical Applications of Research. The conference was cosponsored by the NIH Office of Research on Women's Health.

1. What Is the Scientific Evidence to Support a Conceptualization of Opiate Dependence as a Medical Disorder Including Natural History, Genetics and Risk Factors, and Pathophysiology, and How Is Diagnosis Established?

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

Suggested Citation:"Appendix F: National Institute of Health Consensus Development Statement on Effective Medical Treatment of Heroin Addiction." Institute of Medicine. 1998. Bridging the Gap Between Practice and Research: Forging Partnerships with Community-Based Drug and Alcohol Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6169.
×

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 opiate-addicted population. As a population of opiate addicts age, there is a decrease in the percentage who are still addicted.

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 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 (6.7-fold increased risk), alcoholism (3.5), antisocial personality (7.6), and unipolar depression (5.1) among the first-degree relatives of opiate-dependent 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

Suggested Citation:"Appendix F: National Institute of Health Consensus Development Statement on Effective Medical Treatment of Heroin Addiction." Institute of Medicine. 1998. Bridging the Gap Between Practice and Research: Forging Partnerships with Community-Based Drug and Alcohol Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6169.
×

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 drug-taking. Dependence may occur with or without the physiological symptoms of tolerance and withdrawal. Usually, there is a long history of opioid self-administration, 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/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.

Suggested Citation:"Appendix F: National Institute of Health Consensus Development Statement on Effective Medical Treatment of Heroin Addiction." Institute of Medicine. 1998. Bridging the Gap Between Practice and Research: Forging Partnerships with Community-Based Drug and Alcohol Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6169.
×

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 self-administration even when there is an expressed and demonstrated strong motivation and powerful social consequences to stop.
  • Continuous exposure to opioids induces pathophysiologic changes in brain.

2. What Are the Consequences of Untreated Opiate Dependence to Individuals, Families, and Society?

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 are 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

Prior to 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.

Suggested Citation:"Appendix F: National Institute of Health Consensus Development Statement on Effective Medical Treatment of Heroin Addiction." Institute of Medicine. 1998. Bridging the Gap Between Practice and Research: Forging Partnerships with Community-Based Drug and Alcohol Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6169.
×

The most striking evidence of the effectiveness of MMT on death rates are studies directly comparing these rates in opiate-dependent persons, on and off methadone. Every study showed that death rates were lower in opiate-dependent 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 is 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 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.

Suggested Citation:"Appendix F: National Institute of Health Consensus Development Statement on Effective Medical Treatment of Heroin Addiction." Institute of Medicine. 1998. Bridging the Gap Between Practice and Research: Forging Partnerships with Community-Based Drug and Alcohol Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6169.
×

Joblessness

Opiate dependence prevents many users from maintaining steady employment. Much of their time each day is spent in drug-seeking and drug-taking 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. Based on 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.

3. What Is the Efficacy of Current Treatment Modalities in the Management of Opiate Dependence 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 Dependence?

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-a-day 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 presently 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 nonaddicting 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 re-

Suggested Citation:"Appendix F: National Institute of Health Consensus Development Statement on Effective Medical Treatment of Heroin Addiction." Institute of Medicine. 1998. Bridging the Gap Between Practice and Research: Forging Partnerships with Community-Based Drug and Alcohol Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6169.
×

quire 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

Nonpharmacologic 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.

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

Suggested Citation:"Appendix F: National Institute of Health Consensus Development Statement on Effective Medical Treatment of Heroin Addiction." Institute of Medicine. 1998. Bridging the Gap Between Practice and Research: Forging Partnerships with Community-Based Drug and Alcohol Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6169.
×

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 analog 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.

Suggested Citation:"Appendix F: National Institute of Health Consensus Development Statement on Effective Medical Treatment of Heroin Addiction." Institute of Medicine. 1998. Bridging the Gap Between Practice and Research: Forging Partnerships with Community-Based Drug and Alcohol Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6169.
×

4. What Are the Important Barriers to Effective Use of Opiate Agonists in the Treatment of Opiate Dependence in the United States, Including Perceptions and the Adverse Consequences of Opiate Agonist Use and Legal, Regulatory, Financial, and Programmatic Barriers?

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, the people 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 also believe 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.

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 care for opiate dependence. All primary care medical specialties (including general practice, internal medicine, family practice, obstetrics and gynecology, geriatrics, pediatrics, and

Suggested Citation:"Appendix F: National Institute of Health Consensus Development Statement on Effective Medical Treatment of Heroin Addiction." Institute of Medicine. 1998. Bridging the Gap Between Practice and Research: Forging Partnerships with Community-Based Drug and Alcohol Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6169.
×

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 what are 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 methadone

Suggested Citation:"Appendix F: National Institute of Health Consensus Development Statement on Effective Medical Treatment of Heroin Addiction." Institute of Medicine. 1998. Bridging the Gap Between Practice and Research: Forging Partnerships with Community-Based Drug and Alcohol Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6169.
×

treated person will prefer to receive services from an individual physician rather than 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.

5. What Are the Future Research Areas and Recommendations for Improving Opiate Agonist Treatment and Improving Access?

  • What initiates opiate use?
  • Define genetic predispositions
  • Do some individuals take opiates to treat a preexisting disorder?
  • 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
Suggested Citation:"Appendix F: National Institute of Health Consensus Development Statement on Effective Medical Treatment of Heroin Addiction." Institute of Medicine. 1998. Bridging the Gap Between Practice and Research: Forging Partnerships with Community-Based Drug and Alcohol Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6169.
×
  • Longer term follow-up studies of patients who complete rapid detoxification is 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 methadone.
  •    

    United States and the cost-effectiveness of methadone maintenance therapy is also needed.

    CONCLUSIONS AND RECOMMENDATIONS

    • 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 offer 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 long-acting agonist treatment programs be reduced.
    • Funding for MMT should be increased.
    Suggested Citation:"Appendix F: National Institute of Health Consensus Development Statement on Effective Medical Treatment of Heroin Addiction." Institute of Medicine. 1998. Bridging the Gap Between Practice and Research: Forging Partnerships with Community-Based Drug and Alcohol Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6169.
    ×
    • 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.

    CONSENSUS DEVELOPMENT PANEL

    Lewis L. Judd, M.D.

    Conference and Panel Chair

    Mary Gilman Marston Professor Chair

    Department of Psychiatry

    School of Medicine

    University of California, San Diego

    La Jolla, California

    Clifford Attkisson, Ph.D.

    Dean of Graduate Studies

    Associate Vice Chancellor for Student Academic Affairs

    Professor of Medical Psychology

    University of California, San Francisco

    San Francisco, California

    Wade Berrettini, M.D., Ph.D.

    Professor of Psychiatry and Director

    Center for Neurobiology and Behavior

    Department of Psychiatry

    School of Medicine

    University of Pennsylvania

    Philadelphia, Pennsylvania

    Nancy L. Buc, Esq.

    Buc & Beardsley

    Washington, DC

    Benjamin S. Bunney, M.D.

    Charles B.G. Murphy Professor and Chairman

    Professor of Pharmacology

    Department of Psychiatry

    Yale University School of Medicine

    New Haven, Connecticut

    Roberto A. Dominguez, M.D.

    Professor and Director of Adult Outpatient Clinic

    Department of Psychiatry University of Miami School of Medicine

    Miami, Florida

    Robert O. Friedel, M.D.

    Heman E. Drummond Professor and Chairman

    Department of Psychiatry and Behavioral Neurobiology

    The University of Alabama at Birmingham

    Birmingham, Alabama

    Suggested Citation:"Appendix F: National Institute of Health Consensus Development Statement on Effective Medical Treatment of Heroin Addiction." Institute of Medicine. 1998. Bridging the Gap Between Practice and Research: Forging Partnerships with Community-Based Drug and Alcohol Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6169.
    ×

    John S. Gustafson

    Executive Director

    National Association of State Alcohol and Drug Abuse Directors, Inc.

    Washington, DC

    Donald Hedeker, Ph.D.

    Associate Professor of Biostatistics

    Division of Epidemiology and Biostatistics

    School of Public Health

    University of Illinois, Chicago

    Chicago, Illinois

    Howard H. Hiatt, M.D.

    Professor of Medicine

    Harvard Medical School

    Senior Physician

    Division of General Medicine

    Brigham and Women's Hospital

    Boston, Massachusetts

    Radman Mostaghim, M.D., Ph.D.

    Greenbelt, Maryland

    Robert G. Petersdorf, M.D.

    Distinguished Professor of Medicine

    University of Washington

    Seattle, Washington

    SPEAKERS

    M. Douglas Anglin, Ph.D.

    "The Natural History of Opiate Addiction"

    Director

    UCLA Drug Abuse Research Center

    Los Angeles, California

    Donald C. Des Jarlais, Ph.D.

    "Transmission of Bloodborne Viruses Among Heroin Injectors"

    Director of Research

    Chemical Dependency Institute

    Beth Israel Medical Center and National Development and Research Institutes

    New York, New York

    David P. Desmond, M.S.W.

    "Deaths Among Heroin Users In and Out of Methadone Maintenance"

    Instructor

    Department of Psychiatry

    University of Texas Health Science Center

    San Antonio, Texas

    Rose Etheridge, Ph.D.

    "Factors Related to Retention and Posttreatment Outcomes in Methadone Treatment: Replicated Findings Across Two Eras of Treatment"

    Senior Research Psychologist

    National Development and Research Institutes, Inc. (NDRI, Inc.)

    Raleigh, North Carolina

    Suggested Citation:"Appendix F: National Institute of Health Consensus Development Statement on Effective Medical Treatment of Heroin Addiction." Institute of Medicine. 1998. Bridging the Gap Between Practice and Research: Forging Partnerships with Community-Based Drug and Alcohol Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6169.
    ×

    Igor I. Galynker, M.D., Ph.D.

    "Methadone Maintenance and Regional Cerebral Glucose Metabolism in Opiate Abusers: A Positron Emission Tomographic Study"

    Physician-in-Charge

    Division of Psychiatric Functional Brain Imaging

    Department of Psychiatry

    Beth Israel Medical Center

    New York, New York

    G. Thomas Gitchel

    "Diversion of Methadone: Expanding Access While Reducing Abuse"

    Chief

    Liaison and Policy Section

    Office of Diversion Control

    U.S. Drug Enforcement Administration

    Washington, DC

    Michael Gossop, Ph.D.

    "Methadone Substitution Treatment in the United Kingdom: Outcome Among Patients Treated in Drug Clinics and General Practice Settings"

    Head of Research, National Addiction Centre

    Institute of Psychiatry

    Maudsley Hospital

    London, United Kingdom

    John Grabowski, Ph.D.

    "Behavioral Therapies: A Treatment Element for Opiate Dependence"

    Director

    Substance Abuse Research Center

    Professor

    Department of Psychiatry

    Health Science Center

    University of Texas, Houston

    Houston, Texas

    Henrick J. Harwood

    "Societal Costs of Heroin Addiction"

    Senior Manager

    The Lewin Group

    Fairfax, Virginia

    Jerome H. Jaffe, M.D.

    "The History and Current Status of Opiate Agonist Treatment"

    Director

    Office for Scientific Analysis and Evaluation

    Center for Substance Abuse Treatment

    Substance Abuse and Mental Health Services Administration

    Rockville, Maryland

    Herbert D. Kleber, M.D.

    "Detoxification with or without Opiate Agonist Treatment"

    Professor of Psychiatry

    Division of Substance Abuse

    Department of Psychiatry

    Columbia University College of Physicians and Surgeons

    New York, New York

    Suggested Citation:"Appendix F: National Institute of Health Consensus Development Statement on Effective Medical Treatment of Heroin Addiction." Institute of Medicine. 1998. Bridging the Gap Between Practice and Research: Forging Partnerships with Community-Based Drug and Alcohol Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6169.
    ×

    Mary Jeanne Kreek, M.D.

    "Opiate Agonist Treatment, Molecular Pharmacology, and Physiology"

    Professor and Head

    Senior Physician

    Laboratory of the Biology of Addictive Diseases

    Rockefeller University

    New York, New York

    David C. Lewis, M.D.

    “Access to Narcotic Addiction Treatment and Medical Care”

    Director, Center for Alcohol and Addiction Studies

    Brown University

    Providence, Rhode Island

    Dennis McCarty, Ph.D

    “Narcotic Agonist Treatment as a Benefir Under Managed Care”

    Human Services Research Professor

    Institute for Health Policy

    Heller Graduate School

    Brandeis University

    Waltham, Massachusetts

    A. Thomas McLellan, Ph.D.

    “Problem-Service Matching in Methadone maintenance Treatment: Policy Suggestions From Two Prospective Studies”

    Scientific Director

    DeltaMetrics in Association with Treatment Research Institute

    Philadelphia, Pennsylvania

    Jeffrey Merrill, Ph.D.

    "Impact of Methadone Maintenance on HIV Seroconversion and Related Costs"

    Director

    Economic and Policy Research

    Treatment Research Institute

    University of Pennsylvania

    Philadelphia, Pennsylvania

    Eric J. Nestler, M.D., Ph.D.

    "Neurobiological Substrates for Opiate Addiction"

    Elizabeth Mears and House Jameson Professor of Psychiatry and Pharmacology Department of Psychiatry

    Connecticut Mental Health Center

    Yale University School of Medicine

    New Haven, Connecticut

    David N. Nurco, D.S.W.

    "Narcotic Drugs and Crime: Addict Behavior While Addicted Versus Nonaddicted'

    Research Professor

    Department of Psychiatry

    University of Maryland School of Medicine Baltimore, Maryland

    Mark W. Parrino, M.P.A.

    "Legal, Regulatory, and Funding Barriers to Good Practice and Associated Consequences"

    President

    American Methadone Treatment Association, Inc.

    New York, New York

    Suggested Citation:"Appendix F: National Institute of Health Consensus Development Statement on Effective Medical Treatment of Heroin Addiction." Institute of Medicine. 1998. Bridging the Gap Between Practice and Research: Forging Partnerships with Community-Based Drug and Alcohol Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6169.
    ×

    J. Thomas Payte, M.D.

    "Methadone Dose and Outcome"

    Medical Director

    Drug Dependence Associates

    San Antonio, Texas

    Roy W. Pickens, Ph.D.

    "Genetic and Other Risk Factors in Opiate Addiction"

    Senior Scientist

    Division of Intramural Research

    Addiction Research Center

    National Institute on Drug Abuse

    National Institutes of Health

    Baltimore, Maryland

    D. Dwayne Simpson, Ph.D.

    "Patient Engagement and Duration of Treatment"

    Director and S.B. Sells Professor of Psychology

    Institute of Behavioral Research

    Texas Christian University

    Fort Worth, Texas

    Barbara J. Turner, M.D.

    "Prenatal Care and Antiretroviral Use Associated with Methadone Treatment of HIV-Infected Pregnant Women"

    Professor of Medicine

    Director of Research in Health Care

    Thomas Jefferson University

    The Center for Research in Medical Education and Health Care

    Philadelphia, Pennsylvania

    George E. Woody, M.D.

    "Establishing a Diagnosis of Heroin Abuse and Addiction"

    Chief, Substance Abuse Treatment Unit

    Veterans Affairs Medical Center

    Clinical Professor

    Department of Psychiatry

    University of Pennsylvania

    Philadelphia, Pennsylvania

    Joan E. Zweben, Ph.D.

    "Community, Staff, and Patient Perceptions and Attitudes"

    Executive Director

    14th Street Clinic and East Bay Community Recovery Project

    Clinical Professor of Psychiatry

    University of California, San Francisco

    Berkeley, California

    Suggested Citation:"Appendix F: National Institute of Health Consensus Development Statement on Effective Medical Treatment of Heroin Addiction." Institute of Medicine. 1998. Bridging the Gap Between Practice and Research: Forging Partnerships with Community-Based Drug and Alcohol Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6169.
    ×

    PLANNING COMMITTEE

    James R. Cooper, M.D.

    Planning Committee Chair

    Associate Director for Medical Affairs

    Division of Clinical and Services Research

    National Institute on Drug Abuse

    National Institutes of Health

    Rockville, Maryland

    Elsa A. Bray

    Program Analyst

    Office of Medical Applications of Research

    National Institutes of Health

    Bethesda, Maryland

    Mona Brown

    Press Officer

    National Institute on Drug Abuse

    National Institutes of Health

    Rockville, Maryland

    Kendall Bryant, Ph.D.

    Coordinator

    AIDS Behavioral Research

    National Institute on Alcohol Abuse and Alcoholism

    National Institutes of Health

    Rockville, Maryland

    Jerry Cott, Ph.D.

    Chief

    Pharmacologic Treatment Research Program

    National Institute of Mental Health

    National Institutes of Health

    Rockville, Maryland

    Donald C. Des Jarlais, Ph.D.

    Director of Research

    Chemical Dependency Institute

    Beth Israel Medical Center and National Development and Research Institutes

    New York, New York

    John H. Ferguson, M.D.

    Director

    Office of Medical Applications of Research

    National Institutes of Health

    Bethesda, Maryland

    Bennett Fletcher, Ph.D.

    Acting Chief

    Services Research Branch

    Division of Clinical and Services Research

    National Institute on Drug Abuse

    National Institutes of Health

    Rockville, Maryland

    Joseph Frascella, Ph.D.

    Chief

    Etiology and Clinical Neurobiology Branch

    Division of Clinical and Services Research

    National Institute on Drug Abuse

    National Institutes of Health

    Rockville, Maryland

    G. Thomas Gitchel

    Chief, Liaison and Policy Section

    Office of Diversion Control

    U.S. Drug Enforcement Agency

    Washington, DC

    Suggested Citation:"Appendix F: National Institute of Health Consensus Development Statement on Effective Medical Treatment of Heroin Addiction." Institute of Medicine. 1998. Bridging the Gap Between Practice and Research: Forging Partnerships with Community-Based Drug and Alcohol Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6169.
    ×

    William H. Hall

    Director of Communications

    Office of Medical Applications of Research

    National Institutes of Health

    Bethesda, Maryland

    Jerome H. Jaffe, M.D.

    Director, Office for Scientific Analysis and Evaluation

    Center for Substance Abuse Treatment

    Substance Abuse and Mental Health Services Administration

    Rockville, Maryland

    Lewis L. Judd, M.D.

    Panel and Conference Chair

    Mary Gilman Marston Professor

    Chair, Department of Psychiatry

    School of Medicine

    University of California, San Diego

    La Jolla, California

    Herbert D. Kleber, M.D.

    Professor of Psychiatry

    Division of Substance Abuse

    Department of Psychiatry

    Columbia University College of Physicians and Surgeons

    New York, New York

    Mitchell B. Max, M.D.

    Chief, Clinical Trials Unit

    Neurobiology and Anesthesiology Branch

    National Institute of Dental Research

    National Institutes of Health

    Bethesda, Maryland

    A. Thomas McLellan, Ph.D.

    Scientific Director

    DeltaMetrics in Association with Treatment Research Institute

    Philadelphia, Pennsylvania

    Eric J. Nestler, M.D., Ph.D.

    Elizabeth Mears and House Jameson Professor of Psychiatry and Pharmacology

    Department of Psychiatry

    Connecticut Mental Health Center

    Yale University School of Medicine

    New Haven, Connecticut

    Stuart Nightingale, M.D.

    Associate Commissioner for Health Affairs

    U.S. Food and Drug Administration

    Rockville, Maryland

    Roy W. Pickens, Ph.D.

    Senior Scientist, Division of Intramural Research

    Addiction Research Center

    National Institute on Drug Abuse

    National Institutes of Health

    Baltimore, Maryland

    Nick Reuter, M.P.H.

    Associate Director for Domestic and International Drug Control

    U.S. Food and Drug Administration

    Rockville, Maryland

    Suggested Citation:"Appendix F: National Institute of Health Consensus Development Statement on Effective Medical Treatment of Heroin Addiction." Institute of Medicine. 1998. Bridging the Gap Between Practice and Research: Forging Partnerships with Community-Based Drug and Alcohol Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6169.
    ×

    Charles R. Sherman, Ph.D.

    Deputy Director

    Office of Medical Applications of Research

    National Institutes of Health

    Bethesda, Maryland

    Alan Trachtenberg, M.D., M.P.H.

    Medical Officer

    Office of Science Policy and Communications

    National Institute on Drug Abuse

    National Institutes of Health

    Rockville, Maryland

    Frank Vocci, Ph.D.

    Acting Director

    Medications Development Division

    National Institute on Drug Abuse

    National Institutes of Health

    Rockville, Maryland

    Anne Willoughby, M.D., M.P.H.

    Chief

    Pediatric, Adolescent and Maternal AIDS Branch

    Center for Research for Mothers and Children

    National Institute of Child Health and Human Development

    National Institutes of Health

    Rockville, Maryland

    Stephen R. Zukin, M.D.

    Director

    Division of Clinical and Services Research

    National Institute on Drug Abuse

    National Institutes of Health

    Rockville, Maryland

    CONFERENCE SPONSORS

    Office of Medical Applications of Research, NIH

    John H. Ferguson, M.D., Director

    National Institute on Drug Abuse

    Alan I. Leshner, Ph.D.

    CONFERENCE COSPONSORS

    Office of Research on Women's Health, NIH

    Vivian W. Pinn, M.D., Director

    Suggested Citation:"Appendix F: National Institute of Health Consensus Development Statement on Effective Medical Treatment of Heroin Addiction." Institute of Medicine. 1998. Bridging the Gap Between Practice and Research: Forging Partnerships with Community-Based Drug and Alcohol Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6169.
    ×

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    ×

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    Suggested Citation:"Appendix F: National Institute of Health Consensus Development Statement on Effective Medical Treatment of Heroin Addiction." Institute of Medicine. 1998. Bridging the Gap Between Practice and Research: Forging Partnerships with Community-Based Drug and Alcohol Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6169.
    ×

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    Suggested Citation:"Appendix F: National Institute of Health Consensus Development Statement on Effective Medical Treatment of Heroin Addiction." Institute of Medicine. 1998. Bridging the Gap Between Practice and Research: Forging Partnerships with Community-Based Drug and Alcohol Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6169.
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    Suggested Citation:"Appendix F: National Institute of Health Consensus Development Statement on Effective Medical Treatment of Heroin Addiction." Institute of Medicine. 1998. Bridging the Gap Between Practice and Research: Forging Partnerships with Community-Based Drug and Alcohol Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6169.
    ×
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    Suggested Citation:"Appendix F: National Institute of Health Consensus Development Statement on Effective Medical Treatment of Heroin Addiction." Institute of Medicine. 1998. Bridging the Gap Between Practice and Research: Forging Partnerships with Community-Based Drug and Alcohol Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6169.
    ×
    Page 199
    Suggested Citation:"Appendix F: National Institute of Health Consensus Development Statement on Effective Medical Treatment of Heroin Addiction." Institute of Medicine. 1998. Bridging the Gap Between Practice and Research: Forging Partnerships with Community-Based Drug and Alcohol Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6169.
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    Suggested Citation:"Appendix F: National Institute of Health Consensus Development Statement on Effective Medical Treatment of Heroin Addiction." Institute of Medicine. 1998. Bridging the Gap Between Practice and Research: Forging Partnerships with Community-Based Drug and Alcohol Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6169.
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    Suggested Citation:"Appendix F: National Institute of Health Consensus Development Statement on Effective Medical Treatment of Heroin Addiction." Institute of Medicine. 1998. Bridging the Gap Between Practice and Research: Forging Partnerships with Community-Based Drug and Alcohol Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6169.
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    Suggested Citation:"Appendix F: National Institute of Health Consensus Development Statement on Effective Medical Treatment of Heroin Addiction." Institute of Medicine. 1998. Bridging the Gap Between Practice and Research: Forging Partnerships with Community-Based Drug and Alcohol Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6169.
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    Suggested Citation:"Appendix F: National Institute of Health Consensus Development Statement on Effective Medical Treatment of Heroin Addiction." Institute of Medicine. 1998. Bridging the Gap Between Practice and Research: Forging Partnerships with Community-Based Drug and Alcohol Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6169.
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    Page 204
    Suggested Citation:"Appendix F: National Institute of Health Consensus Development Statement on Effective Medical Treatment of Heroin Addiction." Institute of Medicine. 1998. Bridging the Gap Between Practice and Research: Forging Partnerships with Community-Based Drug and Alcohol Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6169.
    ×
    Page 205
    Suggested Citation:"Appendix F: National Institute of Health Consensus Development Statement on Effective Medical Treatment of Heroin Addiction." Institute of Medicine. 1998. Bridging the Gap Between Practice and Research: Forging Partnerships with Community-Based Drug and Alcohol Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6169.
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    Suggested Citation:"Appendix F: National Institute of Health Consensus Development Statement on Effective Medical Treatment of Heroin Addiction." Institute of Medicine. 1998. Bridging the Gap Between Practice and Research: Forging Partnerships with Community-Based Drug and Alcohol Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6169.
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    Suggested Citation:"Appendix F: National Institute of Health Consensus Development Statement on Effective Medical Treatment of Heroin Addiction." Institute of Medicine. 1998. Bridging the Gap Between Practice and Research: Forging Partnerships with Community-Based Drug and Alcohol Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6169.
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    Suggested Citation:"Appendix F: National Institute of Health Consensus Development Statement on Effective Medical Treatment of Heroin Addiction." Institute of Medicine. 1998. Bridging the Gap Between Practice and Research: Forging Partnerships with Community-Based Drug and Alcohol Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6169.
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    Suggested Citation:"Appendix F: National Institute of Health Consensus Development Statement on Effective Medical Treatment of Heroin Addiction." Institute of Medicine. 1998. Bridging the Gap Between Practice and Research: Forging Partnerships with Community-Based Drug and Alcohol Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6169.
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    Suggested Citation:"Appendix F: National Institute of Health Consensus Development Statement on Effective Medical Treatment of Heroin Addiction." Institute of Medicine. 1998. Bridging the Gap Between Practice and Research: Forging Partnerships with Community-Based Drug and Alcohol Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6169.
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    Suggested Citation:"Appendix F: National Institute of Health Consensus Development Statement on Effective Medical Treatment of Heroin Addiction." Institute of Medicine. 1998. Bridging the Gap Between Practice and Research: Forging Partnerships with Community-Based Drug and Alcohol Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6169.
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    Suggested Citation:"Appendix F: National Institute of Health Consensus Development Statement on Effective Medical Treatment of Heroin Addiction." Institute of Medicine. 1998. Bridging the Gap Between Practice and Research: Forging Partnerships with Community-Based Drug and Alcohol Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6169.
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    Suggested Citation:"Appendix F: National Institute of Health Consensus Development Statement on Effective Medical Treatment of Heroin Addiction." Institute of Medicine. 1998. Bridging the Gap Between Practice and Research: Forging Partnerships with Community-Based Drug and Alcohol Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6169.
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    Suggested Citation:"Appendix F: National Institute of Health Consensus Development Statement on Effective Medical Treatment of Heroin Addiction." Institute of Medicine. 1998. Bridging the Gap Between Practice and Research: Forging Partnerships with Community-Based Drug and Alcohol Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6169.
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    Suggested Citation:"Appendix F: National Institute of Health Consensus Development Statement on Effective Medical Treatment of Heroin Addiction." Institute of Medicine. 1998. Bridging the Gap Between Practice and Research: Forging Partnerships with Community-Based Drug and Alcohol Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6169.
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    Suggested Citation:"Appendix F: National Institute of Health Consensus Development Statement on Effective Medical Treatment of Heroin Addiction." Institute of Medicine. 1998. Bridging the Gap Between Practice and Research: Forging Partnerships with Community-Based Drug and Alcohol Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6169.
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    Suggested Citation:"Appendix F: National Institute of Health Consensus Development Statement on Effective Medical Treatment of Heroin Addiction." Institute of Medicine. 1998. Bridging the Gap Between Practice and Research: Forging Partnerships with Community-Based Drug and Alcohol Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6169.
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    Suggested Citation:"Appendix F: National Institute of Health Consensus Development Statement on Effective Medical Treatment of Heroin Addiction." Institute of Medicine. 1998. Bridging the Gap Between Practice and Research: Forging Partnerships with Community-Based Drug and Alcohol Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6169.
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    Suggested Citation:"Appendix F: National Institute of Health Consensus Development Statement on Effective Medical Treatment of Heroin Addiction." Institute of Medicine. 1998. Bridging the Gap Between Practice and Research: Forging Partnerships with Community-Based Drug and Alcohol Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6169.
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    Suggested Citation:"Appendix F: National Institute of Health Consensus Development Statement on Effective Medical Treatment of Heroin Addiction." Institute of Medicine. 1998. Bridging the Gap Between Practice and Research: Forging Partnerships with Community-Based Drug and Alcohol Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6169.
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    Suggested Citation:"Appendix F: National Institute of Health Consensus Development Statement on Effective Medical Treatment of Heroin Addiction." Institute of Medicine. 1998. Bridging the Gap Between Practice and Research: Forging Partnerships with Community-Based Drug and Alcohol Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6169.
    ×
    Page 222
    Suggested Citation:"Appendix F: National Institute of Health Consensus Development Statement on Effective Medical Treatment of Heroin Addiction." Institute of Medicine. 1998. Bridging the Gap Between Practice and Research: Forging Partnerships with Community-Based Drug and Alcohol Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6169.
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    Page 223
    Suggested Citation:"Appendix F: National Institute of Health Consensus Development Statement on Effective Medical Treatment of Heroin Addiction." Institute of Medicine. 1998. Bridging the Gap Between Practice and Research: Forging Partnerships with Community-Based Drug and Alcohol Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6169.
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    Page 224
    Suggested Citation:"Appendix F: National Institute of Health Consensus Development Statement on Effective Medical Treatment of Heroin Addiction." Institute of Medicine. 1998. Bridging the Gap Between Practice and Research: Forging Partnerships with Community-Based Drug and Alcohol Treatment. Washington, DC: The National Academies Press. doi: 10.17226/6169.
    ×
    Page 225
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    Today, most substance abuse treatment is administered by community-based organizations. If providers could readily incorporate the most recent advances in understanding the mechanisms of addiction and treatment, the treatment would be much more effective and efficient. The gap between research findings and everyday treatment practice represents an enormous missed opportunity at this exciting time in this field.

    Informed by real-life experiences in addiction treatment including workshops and site visits, Bridging the Gap Between Practice and Research examines why research remains remote from treatment and makes specific recommendations to community providers, federal and state agencies, and other decision-makers. The book outlines concrete strategies for building and disseminating knowledge about addiction; for linking research, policy development, and everyday treatment implementation; and for helping drug treatment consumers become more informed advocates.

    In candid language, the committee discusses the policy barriers and the human attitudes—the stigma, suspicion, and skepticism—that often hinder progress in addiction treatment. The book identifies the obstacles to effective collaboration among the research, treatment, and policy sectors; evaluates models to address these barriers; and looks in detail at the issue from the perspective of the community-based provider and the researcher.

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