California Department of Alcohol and Drug Programs

Methadone has been linked to cardiac arrhythmia. (R)-methadone appears to confer a lower risk of QT interval prolongation, resulting in debate over how best to treat patients needing this medication. A discussion of salient aspects of selecting therapy for opioid dependence and pain management and decision-making regarding methadone formulation follows.

Abstract This article reports the overall statewide findings of an epidemiological study that included 29,494 pregnant women who had been admitted for delivery in more than 200 hospitals in California and who were tested for alcohol and other drugs via blind urine toxicology screens. Results were matched to demographic data. The article includes analysis and discussion of four major variables: race/ethnic group differences, acculturation, source of payment for birth, and prenatal care status. Regional results are also discussed. The authors emphasize the high rate of alcohol use and selfreported tobacco use in comparison to relatively low rates of illicit drug use. Alcohol use rates were fairly stable, while use of illicit drugs and tobacco tended to vary according to social and demographic variables. The findings establish the need for both broad-based and targeted prevention and intervention programs to better disseminate the risks involved in drinking alcohol, smoking tobacco. and using drugs during pregnancy.

The Contra Costa County educational program for juveniles found guilty of driving under the influence (DUI) was evaluated. Over 600 juveniles convicted of DUI from 1983 to 1988 formed the study group for this research and of these over 100 participated in the educational program. Assessment of program participants was conducted for knowledge, attitudes and behavior. Participants demonstrated increased knowledge, stronger attitudes against driving under the influence, and less risky alcohol and automobile related behaviors. County juvenile records analyzed by the logit procedure showed that class participants had a significantly lower number of repeat offenses compared to non-program participants that could not be explained by race, offense severity, age or gender.

The North of Market Older Women's Alcohol Program is an innovative outreach program designed to assist isolated and impoverished alcohol-dependent older women. The program utilized service components focused on "building up" the clientele and developing support networks rather than the traditional approach of first "breaking down" an alcoholic's defense barriers. Sobriety (complete abstinence) was attained by 60% of the women for a minimum of 3 months (not necessarily consecutive).

Wallner and colleagues present new and interesting findings on the range of electrocardiographic abnormalities in a sample of opioid-dependent patients receiving a variety of opioid therapies [1]. This paper is especially timely because of increasing concerns over the effect of methadone on cardiac function, specifically cardiac rhythm and possible lengthening of cardiac QT interval. While they report QTc prolongation to occur more frequently with methadone in a dose-dependent fashion, ST abnormalities occurred at greatest frequency in this sample, followed by QTc prolongation, tall R or S waves, and pathologic Q waves, all of which occurred at higher frequencies than for the general population. However, other abnormalities were observed at rates that do not appear to be substantially greater or were lower than those reported for the general population. Importantly, the association of electrocardiographic abnormalities with illicit substance use by those who are opioid-maintained was demonstrated. One disappointing aspect of this study was the decision not to collect data on nicotine and alcohol use. Nicotine, principally through cigarette smoking, has been unequivocally linked to cardiac disease. Ischemic heart disease, cardiac arrhythmias, and endothelial dysfunction leading to atherosclerosis have been strongly linked to cigarette smoking [2]. Particularly pertinent to this topic is preclinical data showing that nicotine blocks potassium channels which might explain the association between nicotine consumption and sudden death [3]. Similarly, alcohol abuse has been associated with arrhythmias, hypertension and cardiomyopathy [4] while heavy drinking has also been associated with sudden death in addition to the aforementioned conditions [5]. Because of the high rates of comorbid alcohol use disorders and nicotine dependence in opiate-addicted individuals [6,7] and the possible contribution of these substances to observed electrocardiographic findings, the authors missed an opportunity to explore the possible effect of polysubstance abuse on cardiac function. Rather than assume such history would be unreliable, it would have added to this study to have collected history from participants and confirmed recent use via ethyl glucuronide testing for alcohol and cotinine levels for nicotine. Despite this flaw in the study design, the findings are still important and warrant consideration. The increased awareness of the potential danger of methadone on cardiac function, specifically QT prolongation and development of severe and sometimes fatal cardiac arrhythmias, dates back to a series of ten fatalities recorded from 1997–2000 in l-alpha-acetylmethadol (LAAM)-treated patients in which ventricular rhythm disorders including torsades de pointes occurred [8]. This led to the decision by the European Medicines Agency (EMEA) to remove LAAM from the European market. The US Food and Drug Administration (FDA) opted to black-box label LAAM and make it a second-line drug for the treatment of opioid dependence, rather than removing it from the US market. However, new guidelines were also developed requiring electrocardiographic monitoring. In the face of no such requirements for methadone maintenance treatment, LAAM use declined, leading the manufacturer to stop production with its resultant loss as a treatment option for opioid dependence. Arguably, thousands of patients were denied continuation with, and access to, a medication that had been valuable in the treatment of opiate addiction. While it could be argued that methadone was made available to all of these individuals, it should be pointed out that opiate-addicted patients need as many pharmacotherapy options as possible. LAAM offered advantages over methadone in its thrice weekly dosing making it possible for patients to become gainfully employed and to have less life disruption than that required by regulations regarding methadone maintenance treatment. For some patients, LAAM assisted with withdrawal and craving more effectively than methadone. Since the relationship between LAAM and prolonged QT interval became known, there has been increased scrutiny of methadone for similar effects. Methadone has been associated with lengthening of the QT interval [9,10] and with the potential for inducing ventricular arrhythmia including torsades de pointes [9,11]. This effect appears to be dose-related with higher doses more likely to increase risk, although lower doses are not without risk as well. The question is how to address the increased risk of electrocardiographic abnormalities particularly in asymptomatic patients, given the risk of QT interval prolongation. Certainly the benefits of methadone have been well established in the treatment of opiate addiction [12,13]. The literature would support the evaluation of cardiac history and family history of cardiac disease in all opioid-dependent patients receiving methadone. Those with a history of syncopy or family history of sudden death or other cardiac risk factors should receive a baseline cardiogram. Individuals with QTc at or above upper limits of normal and/or those maintained on higher methadone doses will require clinical monitoring and periodic cardiograms. Methadone doses should be kept as low as possible while conferring clinical effectiveness. Physicians, clinicians and patients need to be educated about this issue. Most physicians are aware of the effect of LAAM on QT interval, but far fewer know of the potential for methadone to produce the same effect [14]. Patients need to be aware of the risks and benefits of opioid therapy and they need to understand the added risk of continued abuse of other illicit drugs, the likely risk of cigarette smoking and alcohol abuse, as well as the potential for drug interactions when these substances are ingested simultaneously including increased risk for arrhythmia [15,16]. Clinicians must diagnose and actively treat co-occurring substance use disorders. Being aware of co-occurring medical and mental illnesses and treatments is also important to the clinical care of patients receiving opioid therapies. Such interventions can increase the safety of methadone treatment. Other interventions include treatment with buprenorphine for those found to have cardiac risk factors as buprenorphine does not appear to significantly alter QT interval relative to methadone or LAAM [17,18] as well as research to find other opioid therapies that might confer greater safety with chronic use such as the active metabolite of LAAM, noracetylmethadol, which does not appear to significantly block HERG cardiac K(+) channels [19]. Finally, since we can now develop guidelines for cardiac monitoring in opioid therapy and patient selection criteria, perhaps we should also consider bringing back LAAM. Supported by NIDA/NIH K24 DA 023359 None.

Improving the care for individuals with substance use disorders is a national health policy priority. Like other parts of the health care system, the addiction field is under pressure for higher accountability-more efficient use of treatment resources, the delivery of quality services, and the production of positive client outcomes. This introductory article highlights the importance of the collection of articles being published in this special issue as they describe California's efforts toward making the alcohol and drug (AOD) treatment system more accountable and effective.

State agencies have been profoundly impacted by the AIDS epidemic. In the absence of a vaccine that would prevent AIDS or of medicines that would cure it, the primary strategies of such agencies have focused on reducing the spread of AIDS by promoting cessation of high risk behaviors and thus preventing or slowing its transmission. Recent research indicates that the primary route of AIDS transmission into the general heterosexual population is by intravenous (IV) drug abusers, who directly account for about 17% of AIDS cases nationwide. Reducing the spread of AIDS within this group would not only reduce the overall toll of the disease but should limit its spread to the population at large. Infection by the human immunodeficiency virus (HIV) can be minimized by reducing or eliminating certain high-risk activities. In the IV drug using community, the primary intervention strategies include: educating IV drug users about the hazards of AIDS and sharing of needles; enrolling them in treatment programs to reduce drug use; promoting the use of new or sterilized syringes and needles among those who will not abstain from drug use; and discouraging high-risk sexual activity among those who are already infected by HIV. The State of California has already increased the number of treatment slots for IV drug users and, through the Department of Alcohol and Drug Programs, is scaling up its educational, prevention, and intervention activities, particularly those related to safe sex, promoting the cessation of IV drug use, and improving equipment hygiene by those who continue use.

This study explores through a mail questionnaire alcohol problems and solutions in Spain and Portugal including: drunk-driving, treatment services and prevention, economic issues, alcohol consumption, cultural aspects, and supply of alcoholic beverages. Consumption of alcohol in both countries is lower for men and women with college educations. Marital status has minimal effects on the consumption level of men and women in Spain and of men in Portugal. For Portuguese married women, consumption is higher. Too many bars and feasts are primary cultural adjuncts contributing to alcohol problems.

(1997). Blending Policy and Research: The California Outcomes Study. Journal of Psychoactive Drugs: Vol. 29, PIONEERING TREATMENT AND RECOVERY MODELS, pp. 161-163.

(2010). Substance Abuse Research Consortium (SARC) Introduction: Moving Forward to Improve Addiction Treatment in California. Journal of Psychoactive Drugs: Vol. 42, SARC Supplement No. 6. Research to Policy: California Substance Abuse Research Consortium Meetings 2009, pp. 205-206.

The forty-first and forty-second semiannual meetings of the Substance Abuse Research Consortium in the spring and fall of 2010 brought together two segments of the alcohol and other drug (AOD) prev...