NIDA Notes: 2010, V23(3), December: Cocaine Vaccine Helps Some Reduce Drug Abuse

2010·1.5 MB·English

www.drugabuse.gov Volume 23, Number 3 U.S. Department of Health and Human Services | National Institutes of Health
Cocaine Vaccine Helps Some
ALSO IN THIS ISSUE
Reduce Drug Abuse
Research Findings
8 Study Supports
A clinical trial encourages continued development of strategy based Methadone Maintenance
in Therapeutic
on immune system response. Communities
11 Marijuana Linked With
Testicular Cancer
drug will not produce the euphoria or other psy-
BY LORI WHITTEN, 13 Multidimensional Family
NIDA Notes Staff Writer choactive effects that reinforce drug taking and Therapy for Adolescent
Drug Abuse Offers Broad,
addiction.
Lasting Benefits
A vaccine to prevent cocaine abuse For the first placebo-controlled test of the
Director’s Perspective
proved mildly effective in its first vaccine’s ability to reduce cocaine use among
2 Incentives Promote
placebo-controlled test. Although people who are addicted to the drug, Dr. Kosten Abstinence
their individual responses varied, and colleagues recruited 115 men and women Research in Brief
vaccine recipients reduced their cocaine use who were seeking treatment at an outpatient 3 • Substance Abuse Among
Women With Children
more quickly than placebo recipients. A sub- clinic after having abused cocaine for about
• Deep Brain Stimulation
group of vaccinated patients generated lev- 15 years. The study participants were taking Reduces Rats’ Cocaine
Seeking • Intervention
els of antibodies that were sufficient to block cocaine, on average, three times daily, 3 days Improves Abstinence,
cocaine’s effects, and during the period of peak per week. All were also addicted to opioids and Employment Among
Welfare Recipients
antibody production, they submitted more had initiated methadone maintenance therapy
NIDA at Work
drug-free urine samples than participants in 2 weeks prior to their first dose of the cocaine
4 Workgroup Keeps NIDA on
the placebo group or those who did not respond the Cutting Edge of Brain
strongly to the vaccine. With further refinement Anti-cocaine antibodies Science
to increase response, a vaccine might someday latch onto cocaine molecules Bulletin Board
be available as a therapy for cocaine abuse, says in the bloodstream and 16 • NIDA Appoints New
Director of the Intramural
lead investigator Dr. Thomas Kosten of Baylor keep them from entering Research Program
• Addiction Science
College of Medicine in Houston.
the brain. Awards Announced
• Program Enhances
Physician Knowledge on
TESTING THE CONCEPT vaccine or placebo. The researchers chose this Substance Abuse • NIDA
Grantee Wins Prize for
The cocaine vaccine consists of a small population because the patients came to the
Genetics Web Sites • Three
amount of the drug chemically bonded to a clinic daily to receive their doses of metha- Scientists Join Advisory
Council
protein, derived from cholera toxin, that stimu- done, thereby increasing the likelihood that
Update
lates the immune system to produce antibodies they would be available for injections, as well as
18 • Parental Supervision
(see illustration, page 6). Anti-cocaine antibod- urine and blood tests, and would remain in the and Genetics Interact
To Influence Nicotine
ies latch onto cocaine molecules in the blood- study for its full 24-week duration.
Addiction • Modafinil
stream, forming drug-antibody complexes that Dr. Kosten and colleagues randomly Normalizes Sleep During
Early Cocaine Abstinence
are too large to pass through the fine-grained assigned 58 patients to receive the cocaine vac-
Tearoff
tissue filter that enwraps and protects the brain. cine in five intramuscular injections spaced
19 NSDUH: Drug Abuse Levels
If the vaccinated person develops enough anti- over 12 weeks, a regimen that previous research Rising
bodies to capture and hold onto most of the had suggested should cumulatively produce What the Numbers Say
cocaine molecules circulating in the blood, the enough antibodies to neutralize the amount of 20 Prisons Lack Detox Services
[ Continued on page 6 ]
NIDA Notes | Volume 23, Number 3 1
■ DIRECTOR’S PERSPECTIVE By NORA D. VOLKOW, M.D., NIDA Director NIDA Notes
EDITOR
David Anderson
Public Health Advisor, Office of Science Policy
and Communications, National Institute on
Drug Abuse
DEPUTY EDITOR
Incentives Promote Julie Ann Miller, Ph.D.
RTI International
MANAGING EDITOR
Abstinence
Andrew Keegan
RTI International
SENIOR SCIENCE WRITER
Lori Whitten, Ph.D.
S RTI International
taying the course and achieving abstinence in substance abuse treatment are
ASSOCIATE EDITOR
two strong indicators that a patient is on the way to stable recovery. Patients
Debra P. Davis
who attend more therapy sessions gain more assets for long-term recovery, such RTI International
as drug-avoidance skills and awareness of the benefits of healthy recreational DESIGN/LAYOUT
Maggie Bray
activities and drug-free social networks. During drug-free intervals, patients accumulate
RTI International
experience in living without drugs.
EDITORIAL BOARD
Motivational incentives—tangible rewards for verifiable abstinence—are power- David Anderson, Chair; Public
ful tools for promoting both goals. In typical motivational incentive programs, patients Health Advisor, Office of Science Policy
and Communications
receive vouchers for cash or goods each time they show up for a therapy session, pass a
Nicolette Borek, Ph.D., Research
Breathalyzer test, or submit a drug-free urine sample. Studies have shown that substance Psychologist, Division of Clinical Neuroscience
and Behavioral Research
abuse patients are better able to maintain desirable behaviors when they are rewarded
Scott Chen, Ph.D. , M.B.A., Scientific Review
daily or weekly rather than when they are asked to focus solely on the ultimate goal of
Officer, Office of Extramural Affairs
long-term recovery. This accords with other research showing that addiction changes the J.C. Comolli, Public Health Advisor,
brain in ways that make individuals more responsive to short-term rewards and less able Division of Pharmacotherapies and Medical
Consequences of Drug Abuse
to forgo them in the interest of longer term benefits.
Jennifer Elcano, M.A., Science Writer,
Incentives extend abstinence during treatment for addiction to cocaine, methamphet- Office of Science Policy and Communications
amine, opioids, and nicotine, and they help cocaine abusers remain in treatment longer. Lynda Erinoff, Ph.D., Associate
Director, AIDS Research Program, Division
Although the effectiveness of incentives tends to weaken after they are discontinued,
of Epidemiology, Services and Prevention
some studies have found that benefits persist for 1 to 2 years. Research
Motivational incentives can promote and reinforce multiple healthy behaviors. For Petra Jacobs, M.D., Associate Director
for Program Development, Center for Clinical
example, such interventions have improved drug abusers’ adherence to HIV antiviral Trials Network
medication regimens and helped patients maintain regular exercise, job-hunting, and Jacqueline Lloyd, Ph.D., Health Science
Administrator, Division of Epidemiology,
other activities that support a drug-free lifestyle. Investigators are currently examining
Services and Prevention Research
how to tailor incentive programs for adolescents and pregnant women.
Marsha F. Lopez, Ph.D. , Health Science
Motivational incentives need not strain budgets. NIDA-supported researchers have Administrator, Division of Epidemiology,
Services and Prevention Research
developed a program in which the rewards cost about $200 per patient. Each drug-free
Ivan Montoya, M.D., M.P.H., Medical
sample earns the right to draw from a container of chips. Most of the chips say “good job” Officer, Division of Pharmacotherapies and
or can be traded for $1 prizes, such as personal care products and bus tokens, but a few Medical Consequences of Drug Abuse
Mary Pfeiffer, Ph.D., Editor and Writer,
can be exchanged for prizes of greater value, such as music and video players. In a study
Intramural Research Program
conducted in the community-based facilities of the Clinical Trials Network, adding this
Kenzie Preston, Ph.D., Chief, Clinical
program to usual care quadrupled the likelihood of stimulant abusers attaining 12 weeks Pharmacology and Therapeutics Research
Branch
of continuous abstinence. This is important because the longer patients are continuously
Paul Schnur, Ph.D., Deputy Director,
abstinent, the greater their chances of maintaining future abstinence. NIDA hopes that Division of Basic Neuroscience and Behavioral
these findings will encourage more clinics to adopt motivational incentives. ■ Research
Anna Staton, M.P.A., Public Health
Analyst, Office of Science Policy and
Communications
Cora Lee Wetherington, Ph.D.,
Psychologist, Division of Basic Neuroscience
and Behavioral Research
This publication was produced and
printed by RTI International, under
Contract No. HHSN271200900042C
from the National Institute on Drug
Abuse.
2 NIDA Notes | Volume 23, Number 3
■ RESEARCH IN BRIEF Highlights of recently published NIDA-supported studies
less healthy, and more likely response that mimics human stern and colleagues at Colum-
to be unmarried or divorced, relapse to drug abuse. In the bia University. In a study of
unemployed, receiving public Boston experiment, rats that 302 applicants for Temporary
assistance, victims of interper- received 2 hours of deep brain Assistance for Needy Families
sonal violence, and affected by stimulation to the shell area in New Jersey, the research-
serious mental illness. of the nucleus accumbens ers assigned roughly half to
Parental substance abuse (NAc) immediately following an ICM intervention that
increases a child’s risk for the priming injection pressed included weekly visits from
neglect, abuse, and health the lever about half as much as a case manager, help in over-
Substance Abuse and behavioral problems, control animals. coming treatment barriers,
Evaluated Among including poor socialization, Dr. Pierce says his team’s assistance in identifying and
Women With Children attention deficit hyperactiv- findings suggest that deep meeting other patient service
In two nationally representa- ity disorder, depression, and brain stimulation of the needs, and voucher incentives
tive surveys, about 2 percent substance use disorders. Dr. NAc shell holds promise as for remaining in treatment.
of mothers with at-home Simmons and colleagues urge a therapy for severe cocaine The rest of the trial partici-
children under the age of 18 increased attention to detect- addiction. Deep brain stimula- pants received the care welfare
reported symptoms meeting ing and responding to parental tion of a different brain region agencies typically provide to
the clinical criteria for abuse of drug abuse in primary care, has benefited patients with substance-abusing clients,
or dependence on illicit drugs pediatric, and emergency set- Parkinson’s disease, and the which consists of screening
or prescription drugs that are tings and support for research technique is also being tested and referral for treatment.
being misused. to better understand the as a potential therapy for When interviewed after
Dr. Leigh Ann Simmons, impact of parental drug abuse severe depression that does 24 months, 47 percent of the
currently of Duke University, and related factors on chil- not improve with medication. women receiving ICM had
and former colleagues at the dren’s development. > Journal of Neuroscience been abstinent from drugs for
University of Kentucky found > Annals of Epidemiology 28(35):8735–8739, 2008. the past 30 days, compared
that 1.1 percent of the 19,300 19(3):187–193, 2009. with 24 percent of those in the
mothers in this category who usual care group. At that same
responded to the 2002 and Deep Brain time, 22 percent of the women
2003 National Survey on Stimulation Reduces in the ICM group—but only 9
Drug Use and Health had a Rats’ Cocaine Seeking percent of those in the usual
substance use disorder involv- A stream of electrical pulses care group—were employed
ing prescription painkillers, delivered to the brain’s reward full-time. For comparison, the
tranquilizers, sedatives, or center curbs the power of a full-time employment rate was
stimulants; 0.9 percent involv- cocaine injection to spur rats 34 percent among 150 female
ing marijuana; 0.4 percent, to drug seeking. welfare recipients who did not
cocaine; 0.1 percent, heroin; Dr. R. Christopher Pierce abuse drugs.
and 0.2 percent, multiple of Boston University School Intervention The researchers are now
drugs. The overall rates of drug of Medicine and colleagues Improves Abstinence, conducting a cost-benefit
abuse were not higher among trained rats to press a lever to Employment Among analysis of ICM. If their prom-
these women compared with self-administer the drug, then Welfare Recipients ising results are replicated in
other women who participated weaned the rats off that behav- Intensive case management future evaluations, welfare
in the survey. Compared with ior by withholding the drug. (ICM) can help substance- agencies may have an effective
non-drug-using mothers, how- Normally, after rats exposed abusing women who receive tool to help some of their most
ever, mothers who used drugs to this protocol receive a welfare benefits stay off drugs vulnerable clients.
were, on average, younger, priming injection of cocaine, and make strides in employ- > American Journal of Public Health
less educated, more stressed, they resume lever pressing, a ment, report Dr. Jon Morgen- 99(2):328–333, 2009.
NIDA Notes | Volume 23, Number 3 3
■ N I D A A T W O R K :
Neuroscience Consortium Behavioral Research—coordinate the
group’s overall activities. Other mem-
bers initiate and lead activities accord-
Workgroup Keeps NIDA ing to their interests and expertise.
Consortium members seek out and
on the Cutting Edge of share the latest, most promising find-
ings with each other and the rest of the
Brain Science Institute staff. Part of each monthly
Consortium meeting is devoted to what
the group calls Hot Trends in NeuroSci-
announce new tools and insights that ence. One member reports on a research
BY LORI WHITTEN,
NIDA Notes Staff Writer have potential to reduce drug abuse and paper relevant to his or her area. The
addiction and ameliorate their health group discusses the study, focusing on
The past 4 decades have wit- and social consequences. It is the mis- how the results might influence NIDA’s
nessed explosive growth in sion of the Institute’s Neuroscience research. Consortium members then
knowledge about the brain’s Consortium to monitor developments share the information with other NIDA
inner workings. For exam- in brain science and ensure that NIDA’s colleagues whose initiatives might ben-
ple, neuroscientists have identified an research programs are infused with the efit from it.
expanding list of neurochemicals and most current and most powerful knowl- The Consortium also conducts
receptor proteins that form the back- edge and tools. NIDA’s Cutting Edge Seminar series
bone of cell-to-cell communication, for all staff, other NIH researchers, and
developed animal models that mimic SHARING NEUROSCIENCE the public. These seminars enlist speak-
neurological conditions, and parsed KNOWLEDGE ers from outside NIDA—some from
how gene activation and suppression by Neuroscience is progressing so rap- other NIH institutes, others from uni-
environmental factors influence learn- idly that scientists find it challenging versities—for a half-day event focus-
to stay abreast ing on a specific topic. A 2009 Cutting
of advances in Edge Seminar, for example, presented
their own areas, the techniques, findings, and potential
NATIONAL INSTITUTE ON DRUG ABUSE PRESENTS
let alone across of resting state functional connectiv-
the entire field. ity. This promising new neuroimaging
Created in 1994, approach analyzes the network dynam-
NIDA’s Neuro- ics of the whole brain when a subject is
science Consor- awake but not responding to any par-
tium helps NIDA ticular external stimulus. The technique
staff keep pace measures synchronous activity across
with cutting- brain regions. Researchers are investi-
edge brain sci- gating how resting brain dynamics differ
ence related to between normal individuals and people
addiction. The with brain disorders, such as attention
ing and memory. NIDA-funded scien- approximately 50 Consortium members deficit hyperactivity disorder and
tists have contributed to and drawn represent every division of NIDA and bulimia. The technique also exam-
upon these advances as they have estab- virtually all offices, centers, and pro- ines brain dynamics as people shift
lished that drug addiction is a brain grams. Co-chairs of the Neuroscience from the resting state to a task-
disease—the conceptual foundation of Consortium—NIDA’s Science Educa- oriented one. NIDA-funded scientists
effective drug abuse treatment and pre- tion Coordinator Dr. Cathrine Sasek, are examining whether normal brain
vention. Office of Science Policy and Communi- activity during the shifts is disrupted in
Today the rate of discovery in brain cations, and Program Officer Dr. Mary people addicted to drugs.
science is swifter than ever. Each Kautz, Clinical Neuroscience Branch, The Consortium also organizes
week, neuroscience labs and journals Division of Clinical Neuroscience and activities to attract a greater number
4 NIDA Notes | Volume 23, Number 3
of talented scientists to the challenges
FROM PLANT TO PAINKILLER The Use of Resiniferatoxin to Reduce Chronic Pain by
of addiction research. As part of this
Selectively Ablating Spinal C-Fiber, a Cutting Edge Seminar sponsored by the Neuroscience
effort, the Consortium coordinates a Consortium, called NIDA program officers’ attention to research on resiniferatoxin (RTX; below,
NIDA-sponsored Frontiers in Addiction left). That chemical had been extracted from a cactus-like plant, Euphorbia resinifera (below, right)
and seems to provide powerful pain relief. NIDA subsequently facilitated FDA approval for clinical
Mini-Convention at the annual meeting
trials to be conducted by Dr. Andrew Mannes of the NIH Clinical Center. Because RTX does not
of the Society for Neuroscience (SfN), act on brain receptors, it may offer a long-term treatment for some types of chronic pain without
many of the side effects and addiction potential that are associated with opioid analgesics.
the world’s largest forum for research on
brain science and health. The day-long
mini-convention on trends in addiction
research typically draws more than 500
scientists, including many who are new
to addiction science. A highlight is always
an address by the winner of the Jacob P.
Waletzky Memorial Award, selected
by SfN to recognize a junior scientist
conducting innovative research into the
neurobiology of drug addiction.
INFLUENCING NIDA PROGRAMS NIDA Notes, Volume 22, Number 1, page to learn from each other to keep up,”
Consortium activities have had a 1). NIDA staff who coordinate efforts to says Dr. Kautz. “As a program official,
major impact on NIDA research pro- develop safe and effective treatments I find Consortium events thought-
grams and initiatives. For instance, in for pain attended the seminar and subse- provoking and a great opportunity to
a November 2002 Cutting Edge Semi- quently formed a team to seek approval find out about advances in neuroscience.
nar, Dr. Andrew Mannes of the National from the Food and Drug Administration These help NIDA staff to generate creative
Institute of Dental and Craniofacial (FDA) for clinical trials of RTX. In 2008, approaches to the science of addiction.”
Research presented his results from ani- the FDA granted such approval for the Looking to the future, the Consortium
mal research on the pain-fighting effects testing of RTX in patients with pain from plans to continue to highlight exciting
of resiniferatoxin (RTX)—a naturally advanced cancer. Initial findings indicate findings about the brain. “Our goal is to
occurring nonopioid pain reliever with that RTX has strong analgesic power with encourage NIDA scientists to delve into
a different biological target than most no appreciable side effects. new areas of scientific inquiry that have
analgesics (“Basic Science Discoveries “The pace of new findings in neuro- great potential to transform addiction
Yield Novel Approaches to Analgesia,” science is staggering, and it is necessary research,” says Dr. Sasek. ■
NIDAMED: Resources for Patient Care
NIDAMED is a NIDA initiative designed to provide the medical
community with drug abuse resources to enhance patient care.
At the heart of NIDAMED are research-based drug use screening
tools and resources. Designed with the demands of modern clini-
cal practice in mind, these products help clinicians to efficiently
screen at-risk patients and conduct the followup steps necessary
to provide excellent medical care.
Visit www.drugabuse.gov/NIDAMED for more information.
NIDA Notes | Volume 23, Number 3 5
■ COCAINE VACCINE The vaccinated
[ Continued from page 1 ] VACCINE DESIGNED TO KEEP COCAINE OUT OF THE
patients varied
BRAIN Under normal conditions, cocaine molecules (shown as gold
greatly in their anti- circles) easily cross from the blood into the brain (top diagram). A
drug typically in the body during cocaine body responses, and series of vaccines, however, stimulates patients’ immune systems to
produce cocaine antibodies (red Ys) that attach to molecules of the
abuse. The remaining 57 patients received only 38 percent of drug and prevent them from reaching the brain (bottom diagram).
placebo injections on an identical sched- the 55 who complet-
ule. All patients also attended weekly ed the entire series
Unprotected
drug abuse counseling sessions focused of injections pro-
Brain
on relapse prevention. The participants duced anti-cocaine
submitted urine samples for cocaine assay antibodies in the
three times each week and gave blood quantity (at least 43
samples for antibody level monitoring at mg/mL of blood) that
the end of the second week and then at the researchers cal-
4-week intervals. culate will reliably
block drug-induced
ANTIBODY LEVEL CRUCIAL euphoria. During Blood
Some of the patients noted that the the 8 weeks of the Cocaine
vaccine achieved its desired effect of sup- greatest antibody
pressing cocaine’s psychoactive effects. response, this group
These individuals said that they felt little provided cocaine-
Protected by Antibodies
difference even after taking large amounts free urine samples
Brain
of the drug—in some cases up to 10 times 45 percent of the
their normal intake—confirmed by levels time, as compared
of a cocaine metabolite in their urine. In with 35 percent for
most of these cases, loss of cocaine’s psy- the placebo group
choactive effects occurred after three to and the group with
four injections of the vaccine. a lesser response
The patients who received the vaccine to the vaccine. Of
and those given placebo both reduced the patients who Blood
their cocaine use, but the former did so produced euphoria- Cocaine
more rapidly. During the period of highest blocking antibody
antibody response to the vaccine—from levels, 53 percent
the week following the fourth booster at least doubled
injection through the month following the the frequency with
final one—30 percent of the vaccinated which their urine estimates that, with the current vaccine,
patients, but only 15 percent of the place- samples demonstrated no new cocaine about 70 percent of cocaine abusers would
bo patients, achieved a 50 percent reduc- use, compared with 23 percent of those develop high enough levels of antibody to
tion in cocaine-positive urine samples who received the vaccine but produced block cocaine’s euphoric effects by more
compared with levels at the beginning of lower levels of the antibodies. than 90 percent, an effect considered suffi-
the study. In prior research, this measure “If a patient makes enough antibod- cient to prevent relapse in individuals moti-
of success corresponded with improve- ies, this treatment works well,” says Dr. vated to quit. However, people not moti-
ments in daily functioning among people Kosten. Among cocaine abusers who vated to quit but who receive the antibody
addicted to cocaine, Dr. Kosten says. No receive the full course of injections, those treatment, perhaps in response to family
further injections were given after the who are motivated to quit are expected pressure or other reasons, would require an
12th week of the study, and the difference to achieve abstinence with a lower level antibody level high enough to completely
in cocaine use between the vaccine and of antibody than those who are not prevent euphoric effects from whatever
placebo groups disappeared by week 16. motivated to quit, he adds. Dr. Kosten amount of cocaine they typically take.
6 NIDA Notes | Volume 23, Number 3
There were no serious adverse events scheduled for daily clinic visits for meth- rier has been used in a human meningitis
related to the vaccine, and no patients adone. To bolster participants’ motiva- vaccine for over 10 years. The newly con-
dropped out of the study because of the tion, the researchers are supplementing figured vaccine has reduced cocaine self-
treatment. “The active protein compo- relapse-prevention behavioral therapy administration in animals but has yet to be
nents of this vaccine (cholera toxin B) and with the opportunity to earn rewards for tried in people.
the adjuvant of aluminum are used widely; keeping clinic appointments. Dr. Kosten envisions a 2-year course of
millions of people have received them,” In other ongoing research with differ- vaccine-aided therapy for cocaine addic-
says Dr. Kosten. “Because the amount ent collaborators, Dr. Kosten is modifying tion that will include behavioral therapy
of cocaine in this vaccine is very small, it
poses no threat to safety.”
There were no serious adverse events related to the
IMPROVING THE VACCINE vaccine, and no patients dropped out of the study
Dr. Kosten’s team is currently plan- because of the treatment.
ning to enroll 300 participants in a large
NIDA-supported multisite trial to confirm
the results of this proof-of-concept study the vaccine in hopes of producing a stron- and a series of vaccine injections followed
and determine whether the vaccine can ger, more sustained antibody response. by bimonthly or quarterly boosters.
benefit the general population of cocaine The researchers have replaced the cholera Dr. Jamie Biswas of NIDA’s Division
abusers. The team expects the challenge toxin with a carrier molecule developed by of Pharmacotherapies and Medical Con-
of retaining patients for the entire course Merck Pharmaceuticals from the Neisseria sequences of Drug Abuse agrees with this
of vaccinations and assessments to be meningitidis bacteria coat protein, which proposed length of treatment: “Patients
greater than in the just-completed trial, has boosted the amount of antibodies need a couple of years of blocking the
however, as none will be opiate abusers produced by other vaccines. This car- cocaine high to get used to being off the
drug, and they may benefit from appropri-
ate behavioral therapies as well.
ANTIBODIES HELP CUT COCAINE ABUSE As the study progressed from week 1 to week “NIDA is interested in vaccines as
16, all patients reduced cocaine abuse—but vaccine recipients did so more quickly and to a greater
a therapeutic strategy for mopping up an
extent. During the vaccination period, those who produced high levels of cocaine-blocking immu-
noglobulin G (IgG) antibodies (greater than or equal to 43 μg/mL) submitted a greater percentage of abused drug before it reaches the brain,
cocaine-free urine samples than participants who had a lesser response to the vaccine or those in
as an alternative to addiction medica-
the placebo group.
tions that influence the nervous system
directly,” Dr. Biswas adds. In addition to
60
the cocaine vaccine, NIDA’s immunother-
apy program supports the development
50
and testing of vaccines for smoking ces-
e sation and to counter overdoses of phen-
e
e-Fr 40 cyclidine (PCP), methamphetamine, and
ns
caiple amphetamine (see “Antibody Fragment
Com 30 Removes Methamphetamine From the
ntgae of Urine Sa 20 Bparagien 6,”) .N IDA Note s, Volume 22, Num b e r ■5,
e
c Active cocaine vaccine wth high lgG levels (>43 µg/mL)
er
P 10 Active cocaine vaccine wth low lgG levels (<43 µg/mL)
SOURCE
Placebo
Martell, B.A., et al. Cocaine vaccine for the treatment
of cocaine dependence in methadone-maintained
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 patients: A randomized double-blind placebo-
controlled efficacy trial. Archives of General Psychiatry
Time Since First Treatment (in weeks) 66(10):1116–1123, 2009.
NIDA Notes | Volume 23, Number 3 7
■ RESEARCH FINDINGS
Study Supports Methadone
Maintenance in Therapeutic
Communities
Methadone-treated and other patients fare equally well.
undermine other members’ unity of pur- peutic community that has been accom-
BY LAURA BONETTA,
NIDA Notes Contributing Writer pose, threatening their progress. Practical modating methadone patients for over 2
and logistical difficulties add to the chal- decades. All the participants were opioid-
Methadone maintenance lenge of merging the two treatments. dependent and met eligibility criteria for
and therapeutic commu- In a recent NIDA-funded study, Dr. methadone maintenance therapy, and
nities are two effective James Sorensen and colleagues at the roughly half were receiving methadone.
treatment approaches University of California, San Francis- The methadone patients were similar to
that are seldom combined. Few metha- co, showed that these issues, although the others in terms of co-occurring stimu-
done patients apply to therapeutic com- significant, need not be prohibitive. lant abuse, psychiatric history, criminal
METHADONE PATIENTS FARE AS WELL AS DRUG-FREE PATIENTS IN A THERAPEUTIC COMMUNITY SETTING At half-yearly
assessments, the proportions of methadone and comparison-group patients testing positive for illicit opioid or stimulant use were statistically equivalent.
In both groups, the number of individuals using opioids or stimulants increased as more people left the treatment program. All study participants were
tracked for 2 years whether or not they left treatment; participants who switched into methadone treatment during the study are included among the
comparison group in this graph.
Methadone Group
Comparison Group
Opioids Stimulants
e 60 60
v
siti
o
g P 40 40
n
sti
e
T 20 20
nt
e
c
Per 0 0
Entry 6 months 12 months 18 months 24 months Entry 6 months 12 months 18 months 24 months
munities, and few therapeutic com- Opioid-dependent patients who were justice involvement, and expected length
munities will accept them. Methadone taking methadone upon admission to a of stay in the therapeutic community.
patients may anticipate that therapeutic therapeutic community fared as well as At the beginning of the study and then
communities will be inhospitable because the rest of the community over 2 years at 6, 12, 18, and 24 months, the research-
many therapeutic communities tradi- of followup. ers tested participants for use of illicit
tionally have held that recovery requires opioids, alcohol, and stimulants (cocaine
abstinence from all psychoactive drugs, EQUIVALENT RESULTS and amphetamine) and questioned them
including medications. Therapeutic com- The researchers recruited 145 men and about drug injection and risky sexual
munities may be concerned that admit- 86 women at the time of their admission behaviors. They used the program’s client
ting methadone-reliant individuals could to Walden House, a San Francisco thera- database and staff logs to determine par-
8 NIDA Notes | Volume 23, Number 3
Many Patients Still Receive Lower Than
Recommended Methadone Doses
Methadone is a synthetic agent that relieves symptoms of In 1988, 1990, and then at 5-year intervals through 2005,
withdrawal from heroin and other opioids by occupying the the researchers surveyed nationally representative samples
same brain receptor as those drugs. This therapy has been of 146 to 172 outpatient treatment facilities. Although the
shown to have many benefits, including reductions in illicit proportion of patients receiving doses below the recom-
drug use, needle-associated diseases, and crime. The treat- mended minimum decreased during this 17-year span, 34
ment can also help a person work and participate in other
percent of patients in 2005 still received methadone doses
normal social interactions.
of less than 60 mg/day, while 17 percent received doses
below 40 mg/day. The study also found that methadone
In the United States, there are about 1,400 methadone
programs strongly advocating an abstinence recovery goal
maintenance programs serving over 254,000 patients,
were the most likely to provide doses of methadone below
according to a 2006 report by the Substance Abuse and
Mental Health Services Administration. Research has estab- 60 mg/day.
lished that most patients require a methadone dose of
60–120 mg/day, depending on their individual responses,
to achieve optimum therapeutic effects. Yet, a study by SOURCE
Drs. Harold Pollack and Thomas D’Aunno at the University Pollack, H.A., and D’Aunno, T. Dosage patterns in methadone treatment:
of Chicago found that many methadone patients receive Results from a national survey, 1988-2005. Health Services Research 43 (6):
lesser doses. 2143–2163, 2008.
ticipants’ retention in treatment. Previ- range of patients, such as those with psy- patients to understand the medication’s
ous studies had indicated that the longer chiatric disorders. Some of these individu- effects and counter negative attitudes
patients stay in treatment, the greater als receive medications to treat their con- toward it, says Dr. Sorensen. “There has
their likelihood of recovery. ditions, “but methadone still remains an to be training about what it is like to be on
By all measured outcomes, the metha- issue,” says Dr. Sorensen. methadone and how to work with individ-
done patients were statistically indistin- A 2005 national survey of 380 thera- uals who are taking it. A program needs
guishable from patients who were not peutic communities by the Institute for to provide staff with strategies that they
receiving that medication. In particular, Behavioral Research at the University can use in working with issues specific
both groups of patients stayed in treat- of Georgia found that only 7 percent of to patients who take methadone, such as
ment for similar periods of time and had therapeutic communities integrated being drowsy and falling asleep at meet-
similar success rates in avoiding illicit opi- methadone treatment into their pro- ings.” He notes that similar problems arise
oids and stimulants (see graph, page 8). grams. A more recent survey by the Sub- with other psychiatric medications.
“The methadone patients’ outcomes stance Abuse and Mental Health Ser- There also are practical hurdles, such
were entirely equivalent to those of vices Administration determined that as difficulty in supplying the medication.
other patients,” says Dr. Sorensen. “That among residential treatment settings, In the United States, methadone is typi-
removes one reason for not admitting including halfway houses and therapeu- cally provided in highly regulated clinics
them to therapeutic communities.” tic communities, only 3.6 percent used that patients initially have to visit each
methadone in their opioid-treatment day to receive their dose; only after several
NECESSARY ADJUSTMENTS programs. months of adherence to the clinic’s regu-
During the past decade, some thera- Therapeutic communities wishing to lations are patients allowed to take home
peutic communities have modified their integrate methadone patients into their a supply of methadone. Unsupervised
programs to be accessible to a broader programs must teach staff and their other trips to a methadone clinic may expose
NIDA Notes | Volume 23, Number 3 9
therapeutic community patients to risks the 2-year mark of the study, a signifi- Partly because of Dr. Sorensen’s work,
such as encounters with drug dealers or cant number—about 30 percent—of the there is now a growing openness toward
old acquaintances who are still abusing individuals who started their residencies the integration of different medical treat-
drugs. Thus, a residential facility accept- in the drug-free group had initiated ment approaches within therapeutic
ing methadone patients needs to provide methadone maintenance therapy.
communities, including addiction phar-
transportation to and from the clinics, Methadone maintenance patients, in
macotherapies. “Dr. Sorensen’s research
as well as a secure place for storing and contrast, tended to continue with their
is helping therapeutic communities
administering the medication. original therapy.
evolve so that they can reach a broader
All these provisions require additional “It is not a trivial matter to incorpo-
spectrum of patient recovery needs,” Dr.
staff and resources, and thus add costs. Yet rate methadone treatment in a residential
Hilton adds. ■
for therapeutic communities that make treatment setting, but we encourage ther-
the investment, the payoff is the capacity apeutic communities to do so,” says Dr.
SOURCES
to provide more patients with the benefits Sorensen. “In that way, they can expand
Chen, T., et al. Residential treatment modifications:
of the therapeutic community model: a the care they are providing to reach more Adjunctive services to accommodate clients on meth-
safe place to interact with peers who share patients.” adone. American Journal of Drug and Alcohol Abuse
experiences, an emphasis on self-reliance, “Dr. Sorensen has shown that thera- 35(2):91–94, 2009.
a program of motivational reinforcement, peutic communities can support the Hettema, J.E., and Sorensen, J.L. Access to care for
and a dedication to recovery. recovery of patients regardless of whether methadone maintenance patients in the United
States. International Journal of Mental Health and
Dr. Sorensen and colleagues note that their therapeutic goals are abstinence
Addiction 7(3):468–474, 2009.
therapeutic communities that adjust to or long-term maintenance,” says Dr.
Sorensen, J.L., et al. Methadone patients in the thera-
accommodate methadone patients give Thomas F. Hilton of NIDA’s Health Ser-
peutic community: A test of equivalency. Drug and
residents a useful treatment option. At vices Research Program.
Alcohol Dependence 100(1–2):100–106, 2009.
CORRECTION: An earlier version of this article attributed the 2005 survey of therapeutic
communities to the Institute for Behavioral Research at Texas Christian University instead of
at the University of Georgia.
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