0
Get Alert
Please Wait... Processing your request... Please Wait.
You must sign in to sign-up for alerts.

Please confirm that your email address is correct, so you can successfully receive this alert.

1
Letters to the Editor   |    
Divided Doses for Methadone Maintenance
VANIA MODESTO-LOWE
Am J Psychiatry 2008;165:1358-1358. doi:10.1176/appi.ajp.2008.08040586

To the Editor: In his editorial, published in the March 2008 issue of the Journal, Bryon Adinoff, M.D. (1) suggests that among addiction specialists, there is worldwide consensus regarding the beneficial effects of methadone maintenance on improving the morbidity and mortality of opioid-dependent populations. Methadone maintenance decreases rates of HIV, hepatitis C, and heroin overdoses. However, a significant number of opioid-dependent individuals do not respond to methadone. In the United States, efforts to improve the clinical usefulness of opioid agonist maintenance resulted in the Food and Drug Administration’s approval of buprenorphine for use in primary care settings. Moreover, Dr. Adinoff’s editorial discussed the potential merits of divided daily doses for methadone maintenance. However, there are possible limitations to this approach as well as related public health implications.

From a public health perspective, the most compelling obstacle in employing this strategy relates to an increase in methadone deaths in various regions within the United States (2). The role of methadone diversion in these fatalities is suggested by an expanding methadone black market, fostering its use among opioid-naive populations (2). Unfortunately, existing systems designed to curtail diversion remain in need of urgent improvement. Meanwhile, dividing daily methadone doses in already understaffed methadone clinics could lead to a relaxation of methadone take-home policies. Can we afford to pay the price of worsening diversion in the midst of an epidemic of prescription opioid abuse? Until the magnitude of the diversion problem improves, methadone clinics are unlikely to embrace the splitting of doses, regardless of its clinical utility.

Another aspect of the editorial that has been overlooked is the premise that craving is an essential precursor to drug use. In Dr. Adinoff’s words, even the most sophisticated neuroimaging study will have limited clinical value, and only patient endorsement of craving can help dosing strategies. Despite this premise, it is important to acknowledge that the definition, measurements, and clinical value of craving have been the subject of much controversy (3). Nevertheless, craving remains widely employed to estimate dosing requirements in methadone clinics. From a clinical perspective, self-reports of craving appear to be most useful, combined with objective measures of functioning. If methadone-maintained, craving-free individuals are nodding off, robbing banks, and using cocaine and benzodiazepines, then the protective value of methadone as well as its credibility among the public declines, irrespective of research findings.

1.Adinoff B: Divided doses for methadone maintenance. Am J Psychiatry 2008; 165:303–305
 
2.Corkery JM, Schifano F, Ghodse AH, Oyefeso A: The effects of methadone and its role in fatalities. Hum Psychopharmacol 2004; 19:565–576
 
3.Modesto-Lowe V, Kranzler HR: Using cue reactivity to evaluate medications for treatment of cocaine dependence: a critical review. Addiction 1999; 94:1639–1651
 
+

References

+The author reports no competing interests.

+This letter (doi: 10.1176/appi.ajp.2008.08040586) was accepted for publication in June 2008.

+

References

1.Adinoff B: Divided doses for methadone maintenance. Am J Psychiatry 2008; 165:303–305
 
2.Corkery JM, Schifano F, Ghodse AH, Oyefeso A: The effects of methadone and its role in fatalities. Hum Psychopharmacol 2004; 19:565–576
 
3.Modesto-Lowe V, Kranzler HR: Using cue reactivity to evaluate medications for treatment of cocaine dependence: a critical review. Addiction 1999; 94:1639–1651
 
+
+

CME Activity

There is currently no quiz available for this resource. Please click here to go to the CME page to find another.
Submit a Comments
Please read the other comments before you post yours. Contributors must reveal any conflict of interest.
Comments are moderated and will appear on the site at the discertion of APA editorial staff.

* = Required Field
(if multiple authors, separate names by comma)
Example: John Doe



Related Content
Books
Manual of Clinical Psychopharmacology, 7th Edition > Chapter 11.  >
Manual of Clinical Psychopharmacology, 7th Edition > Chapter 11.  >
Manual of Clinical Psychopharmacology, 7th Edition > Chapter 11.  >
Gabbard's Treatments of Psychiatric Disorders, 4th Edition > Chapter 17.  >
Gabbard's Treatments of Psychiatric Disorders, 4th Edition > Chapter 14.  >
Topic Collections
Psychiatric News
PubMed Articles