Archives for June, 2011


Buprenorphine vs. Methadone for Heroin Addiction

Researchers in Pisa, Italy recently published findings from a study of heroin addicts treated with either buprenorphine or methadone.  The study was a follow-up to earlier studies by the same group;  one that examined the personality characteristics of heroin addicts, and a second that measured the impact of agonist treatment on psychiatric symptomatology and the quality of life of heroin addicts. The recent third study, published in the Annals of General Psychiatry, divided heroin addicts according to personality traits, and then examined whether these personality traits predicted success with one agonist treatment over another (i.e. methadone vs. buprenorphine). ‘Agonist treatment’ is used in the Italian studies to refer to maintenance with methadone or with buprenorphine—even though buprenorphine is technically a ‘partial agonist’ rather than an ‘agonist.’  Personality characteristics were defined using an instrument called the SCL-90 (Symptom CheckList-90). In the first study, researchers found that the 1000 or so addicts could be divided into five subgroups, according to clusters of symptoms.  One subgroup was characterized by depressive symptoms.  The second was characterized by somatic symptoms, i.e. focus on physical symptoms and complaints.  The third group was characterized by ‘interpersonal sensitivity’ and symptoms of psychosis—such as delusions.  The fourth group had significant panic or anxiety symptoms, and the final group had symptoms related to violence toward self or others, including suicidality and self-mutilation.
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Using Opioids to Treat Chronic Pain

My last post—the one about changing attitudes toward using opioids to treat chronic, nonmalignant pain-- drew angry responses from a couple readers.  One response was a wandering, spiteful paragraph that (among other things) called me ‘unsympathetic’ for describing the changes coming in the near future, even though I have no role in enacting those changes. I see no value in discussing that angry diatribe further - other than to tell the writer ‘don’t shoot the messenger!’ The other post was more thoughtful and deserves a response—as does the post in the comment section by ‘LS.’  Taking that last comment first, I’ll say thank you-- for pointing out something I should have been clearer about.  People who are treated for acute pain—caused by surgery, or from injuries like broken bones or contusions—rarely develop addiction to opioids.  I HAVE had patients presenting with opioid dependence who say that their addiction started after getting pain meds after surgery and discovering that they liked them, but the number of those cases compared to the overall number of people with surgeries and injuries is likely to be a small fraction of cases. Here is the other response to my suggestion that prescribing opioids for chronic pain MAY make things worse:
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PAINful Changes on the Horizon

There are changes afoot in the use of opioid agonists for chronic pain treatment.  This blog has described the epidemic of opioid dependence that has killed tens of thousands of people across the country over the past few years, and the changes are directed toward reducing the harm caused by this epidemic. A number of interventions have been proposed.  Vicodin, the number one-selling medication in the country, contains the opioid hydrocodone combined with acetaminophen, the agent in Tylenol.  Hydrocodone and Vicodin are currently ‘Schedule III’ medications, and will likely move to Schedule II, where oxycodone, Oxycontin, and Percocet are currently assigned.  The change will have significant impact on the use of Vicodin and hydrocodone, since medications classified as Schedule II must be ordered on written prescriptions—i.e. they cannot be called in to the pharmacy.  There are a number of other limitations on Schedule II medications; the prescriptions cannot have refills for example, and a maximum of 90 days of medication can be ordered at any one time.  The laws that govern diversion of Schedule II medications are more strict as well, meaning that trading or selling Vicodin or hydrocodone to a friend or relative will carry significant risk of prosecution—and incarceration. There are proposals for additional certification and training for doctors who prescribe pain medications, beyond the current DEA licenses that typically allow registrants to prescribe all of the controlled substances, without distinguishing between classes or uses of medications.  These proposals anger the ‘pain treatment lobby,’ whose members claim that additional certification requirements will lessen the availability of pain medications.  And they are correct—that is, after all, the whole point of the proposed changes.
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