David M. Novick

Methadone disposition in patients with chronic liver disease

Chronic liver disease is common in methadone‐maintained patients. We studied the disposition of this drug in 14 patients with biopsy‐proved chronic liver disease and five otherwise healthy subjects receiving methadone maintenance treatment. The patients were divided into three groups based on the severity of liver disease, with group I having the most severe disease. The apparent terminal half‐life of methadone was longer in group I than in groups II and III (moderate and mild chronic liver disease, P < 0.01) and the contrast group (P < 0.05). All other kinetic indices determined for group I and all kinetic indices in groups II and III were essentially the same as those in the contrast subjects or in the other patient groups. Seven patients, including all five in group I, had flattened plasma methadone concentration‐time curves. The data suggest that the maintenance dosage of methadone need not be changed in stable chronic liver disease.

The medical status of methadone maintenance patients in treatment for 11 - 18 years

To assess the safety and potential health consequences of long-term methadone maintenance treatment, we identified 111 male patients admitted to methadone maintenance treatment between 1965 and 1968, still enrolled in 1980 and in continuous treatment for at least 10 years. We were able, between 1980 and 1985, to examine patients or review records of 110 patients (99%). Most medical diagnoses, symptomatic complaints, physical examination findings and laboratory test results occurred with similar frequency in the long-term methadone maintenance patients and in a group of 56 long-term heroin addicts. These data suggest that prolonged methadone maintenance treatment is safe and is not associated with unexpected adverse effects.

Outcomes of treatment of socially rehabilitated methadone maintenance patients in physicians' offices (medical maintenance): follow-up at three and a half to nine and a fourth years.

Objective: To determine whether selected socially rehabilitated former heroin addicts maintained on methadone can continue successful rehabilitation while maintained on methadone by primary care physicians rather than licensed clinics. This procedure has been termed “medical maintenance.”Design: Cohort study with 42–111 months of follow-up.Setting: Offices of hospital staff physicians (internists or family practitioners).Patients: The 100 patients met extensive entry criteria, including five or more years in conventional methadone maintenance treatment; stable employment or other productive activity; verifiable financial support; and no criminal involvement, use of illegal drugs, or excessive alcohol use within three or more years.Measurements and main results: Outcome measures used were retention in treatment, discharge for one of several reasons, lost medication incidents, and substance abuse. At one, two, and three years of treatment, 98, 95, and 85 patients, respectively, remained in medical maintenance. Cumulative proportional survival in treatment was 0.735±0.048 at five years and 0.562±0.084 at nine years. After 42–111 months, 72 patients remained in good standing; 15 patients had unfavorable discharges (11 for cocaine use, three for misuse of medication, and one for administrative violations); seven voluntarily withdrew from methadone in good standing (after receiving it for 91–24.4 years); four died; one transferred to a chronic care facility; and one voluntarily left the program.Conclusions: Carefully selected methadone maintenance patients in medical maintenance have a high retention rate and a low incidence of substance abuse and lost medication. Voluntary withdrawal from methadone maintenance after one or two decades is possible. The authors believe that medical maintenance should be made available to appropriate patients in other localities.

Terminal Ileitis Associated With Mycobacterium avium-intracellulare Infection in a Homosexual Man With Acquired Immune Deficiency Syndrome

A 38-yr-old homosexual man developed fever, diarrhea, and weight loss. An upper gastrointestinal examination revealed terminal ileitis, and stains of stool revealed acid-fast bacilli that were subsequently identified as Mycobacterium avium-intracellulare. Antimycobacterial therapy was associated with weight gain and loss of fever and diarrhea. Several months later, cutaneous Kaposis sarcoma was observed. When the patient developed strictures in the terminal ileum, a surgical resection was performed. Numerous granulomas and acid-fast bacilli, later identified as M. avium-intracellulare, were present in the resected terminal ileum. This report demonstrates that infection of the terminal ileum with M. avium-intracellulare in a patient with acquired immune deficiency syndrome can present with a clinical and radiologic picture resembling Crohns disease. It also demonstrates symptomatic improvement of this infection temporally related to the administration of antimycobacterial therapy and the ability of an acquired immune deficiency syndrome patient to tolerate major abdominal surgery.

In vivo and In vitro Studies of Opiates and Cellular Immunity in Narcotic Addicts

Abnormalities of humoral and cellular immunity had been observed in parenteral heroin abusers in studies performed before the epidemic of human immunodeficiency virus (HIV) infection (1,2). In the 1980s, HIV infection, with the resultant development of acquired immune deficiency syndrome (AIDS), became one of the leading causes of morbidity and mortality in parenteral drug abusers (3–5). Due to the long latency period of HIV infection, the number of new cases of AIDS in parenteral drug abusers is expected to increase significantly during the first half of the 1990s. Since HIV infection causes profound impairments of cellular immunity, information on immunologic abnormalities which precede HIV infection in heroin addicts assumes great importance. Such abnormalities could possibly alter the susceptibility of these patients to HIV infection (6) or the rate of progression of HIV infection towards AIDS (7).

Liver function tests in non-parenteral cocaine users

To investigate the effect of cocaine on standard liver function tests (LFT), we studied 46 cocaine users with no history of parenteral drug use or homosexuality. LFT were similar in 21 users of cocaine only (Group A) and 25 users of cocaine and alcohol (Group B). Only three patients, two of whom were hepatitis B carriers, had an alanine aminotransferase level more than five units above normal limits. Group B patients were significantly more likely to complain of headaches, irritability, and loss of memory. We conclude that (1) non-parenteral cocaine use is rarely associated with significant LFT abnormalities and (2) alcohol may potentiate some adverse effects of cocaine.

Clinical and demographic features of patients admitted to a new chemical dependency program in New York City

We reviewed the clinical and demographic features of all 128 patients who were admitted to a new 28-day in-patient chemical dependency program in New York City during the first six months of operation. The medical records were reviewed retrospectively. Alcohol, cocaine, heroin, marijuana and diazepam were the most common substances abused. Parenteral drug abuse at any time was reported by 51 (40%) of the 128 patients, and 42 (33%) were current parenteral drug abusers. Abusers of alcohol only were significantly older than parenteral drug abusers or non-parenteral drug abusers. Patients who were employed at admission had a significantly longer mean length of stay and a higher rate of completion of the program than those who were not employed. We conclude that: (1) parenteral drug abuse is likely to be commonly seen in chemical dependency programs serving middle-income patients in urban areas, (2) alcohol abusers are older than abusers of other drugs, (3) a higher educational level is associated with successful completion of the chemical dependency program, and (4) evaluation programs are needed in all types of chemical dependency treatment.

HIV‐1 infection among intravenous drug users in Manhattan, New York City, from 1977 through 1987

Intravenous drug users are the second largest group to develop the acquired immunodeficiency syndrome, and they are the primary source for heterosexual and perinatal transmission in the United States and Europe. Understanding long-term trends in the spread of human immunodeficiency virus among intravenous drug users is critical to controlling the acquired immunodeficiency syndrome epidemic. Acquired immunodeficiency syndrome surveillance data and seroprevalence studies of drug treatment program entrants are used to trace seroprevalence trends among intravenous drug users in the borough of Manhattan. The virus entered this drug-using group during the mid-1970s and spread rapidly in 1979 through 1983. From 1984 through 1987, the seroprevalence rate stabilized between 55% and 60%--well below hepatitis B seroprevalence rates. This relatively constant rate is attributed to new infections, new seronegative persons beginning drug injection, seropositive persons leaving drug injection, and increasing conscious risk reduction.

Chronic hepatitis B and adenine arabinoside monophosphate (Ara-AMP)

Excerpt To the editor: The study by Garcia and colleagues (1) of adenine arabinoside monophosphate (Ara-AMP) with or without leukocyte interferon compared with placebo as antiviral therapy for chro...