Blog
Editor's Remarks
It is difficult to know which article to emphasize: this week's piece on methadone-associated mortality, or the policy statement of the American Academy of Pediatrics on cannabis.
In the 50 years since Vincent Dole and Marie Nyswander collaborated in devising methadone maintenance, addiction medicine as a discipline has been validated. Methadone was the first robustly-successful strategy for management of opioid dependence since the interdictions of the Harrison Act. It was the product of an unlikely liaison between a 6 1/2 foot tall Rockefeller Institute researcher and a diminutive classically-trained psychiatrist. The product of their efforts provided an authentic medical model of opioid addiction, and an effective treatment for the disease. There was finally a true 20th century role for the physician in the treatment of drug dependence, beyond the management of withdrawal and co-morbidities. Nonetheless, in those 50 years, there continues to be a profession-wide deficiency in understanding the pharmacology of methadone, both its pharmacokinetics and its pharmacodynamics. The apparent simplicity of its employment as a maintenance agent belies the complexities of its protein binding, metabolism, and rates (sic) of elimination. Consequently, its use as an analgesic requires an understanding that goes well beyond that needed for short-acting opioid administration. Without that understanding, as the article by Ray and colleagues in the Journal of the American Medical Association testifies, patients die. Added to this tragic consequence, the value of methadone as a treatment strategy for addiction is undermined and public support for its use is eroded. As 90% of the patients in the study cited this week were being treated for back pain or other musculoskeletal disorders, there is a great likelihood of any primary care physician prescribing methadone for pain at some point in his or her career. Yet it is apparent that training in the principles of such prescription is inadequate nationally. This should serve as an incentive to emphasize the prescribing principles in pharmacological, neuroscience, and behavioral science curricula within medical schools and residency programs.
In the 50 years since Vincent Dole and Marie Nyswander collaborated in devising methadone maintenance, addiction medicine as a discipline has been validated. Methadone was the first robustly-successful strategy for management of opioid dependence since the interdictions of the Harrison Act. It was the product of an unlikely liaison between a 6 1/2 foot tall Rockefeller Institute researcher and a diminutive classically-trained psychiatrist. The product of their efforts provided an authentic medical model of opioid addiction, and an effective treatment for the disease. There was finally a true 20th century role for the physician in the treatment of drug dependence, beyond the management of withdrawal and co-morbidities. Nonetheless, in those 50 years, there continues to be a profession-wide deficiency in understanding the pharmacology of methadone, both its pharmacokinetics and its pharmacodynamics. The apparent simplicity of its employment as a maintenance agent belies the complexities of its protein binding, metabolism, and rates (sic) of elimination. Consequently, its use as an analgesic requires an understanding that goes well beyond that needed for short-acting opioid administration. Without that understanding, as the article by Ray and colleagues in the Journal of the American Medical Association testifies, patients die. Added to this tragic consequence, the value of methadone as a treatment strategy for addiction is undermined and public support for its use is eroded. As 90% of the patients in the study cited this week were being treated for back pain or other musculoskeletal disorders, there is a great likelihood of any primary care physician prescribing methadone for pain at some point in his or her career. Yet it is apparent that training in the principles of such prescription is inadequate nationally. This should serve as an incentive to emphasize the prescribing principles in pharmacological, neuroscience, and behavioral science curricula within medical schools and residency programs.
