Table Of Content·1
ICRO MAREMMANI
THE PRINCIPLES AND PRACTICE OF
METHADONE
TREATMENT
In memory of Vincent P. Dole,
friend and magister
·1
ICRO MAREMMANI, MD
Professor of Addiction Medicine
University of Pisa and Siena, Italy
Chief of “Vincent P. Dole” Dual Diagnosis Unit
“Santa Chiara” University Hospital, Department of Psychiatry
University of Pisa
Co-Director of “G. De Lisio” Institute of Behavioural Sciences
Pisa, Italy, EU
THE PRINCIPLES AND PRACTICE OF
METHADONE
TREATMENT
Pacini Editore Medicina, Via A. Gherardesca, 56121 Ospedaletto, Pisa, Italy, EU
AU-CNS, Via XX Settembre, 83 - 55045 Pietrasanta, Lucca, Italy, EU
2· ·3
2· ·3
Contributors
Emanuele Bignamini, MD
Psychiatrist and Psychoanalist,
Director of Department of Addiction Medicine, National Health System
Local Unit,
Torino, Italy, EU
Stefania Canoniero, MD
Psychiatrist,
Addiction treatment Centre (SerT), National Health System Local Unit,
Albenga and Finale Ligure, Italy, EU
Barbara Capovani, MD
Psychiatrist,
Addiction treatment Centre (SerT), National Health System Local Unit,
Pisa, Italy, EU
Loretta Finnegan, MD
Professor of Pediatrics, Psychiatry and Human Behavior,
Thomas Jefferson University (Retired),
Philadelphia, Pennsylvania USA
Andrea Flego, MD
Psychiatrist,
Director of Department of Addiction Medicine, National Health System
Local Unit (Retired)
Pordenone, Italy, EU
4· ·5
Gilberto Gerra, MD
Chief
Health and Human Development Section, Division for Operations, United
Nations Office on Drugs and Crime,
Vienna
Giuseppe Giuntoli, MD
Psychiatrist,
Medical Director of “Incontro” Therapeutic Community,
Pistoia, Italy, EU
Francesco Lamanna, MD
Psychiatrist,
Addiction treatment Centre (SerT), National Health System Local Unit,
Pisa, Italy, EU
Mercedes Lovrecic, MD
Psychiatrist,
Ministry of Health of the Republic of Slovenia and Institute of Public Heath
of the Republic of Slovenia,
Lubiana, Slovenia, EU
Sonia Lubrano, MD
Psychiatrist,
Addiction treatment Centre (SerT), National Health System Local Unit,
La Spezia, Italy, EU
Alexander Kantchelov, MD
Psychiatrist,
Director of Kantchelov Clinic,
Sofia, Bulgaria, EU
Angelo Giovanni Icro Maremmani, MD
Consultant
Association for the Application of Neuroscientific Knowledge to Social Aims
(AU-CNS),
Pietrasanta, Lucca, Italy, EU
Andrea Michelazzi, MD
General Practitioner
National Health System,
Trieste, Italy, EU
Matteo Pacini, MD
Research Psychiatrist,
“G. De Lisio” Institute of Behavioural Sciences,
Pisa, Italy, EU
4· ·5
Pier Paolo Pani, MD
Psychiatrist,
Social-Health Service, National Health System Local Unit,
Cagliari, Italy, EU
Giulio Perugi, MD
Professor of Psychiatry, University of Pisa, Italy, EU
Director of “G. De Lisio” Institute of Behavioural Sciences
Pisa, Italy, EU
Dina Popovic, MD
Psychiatrist,
“G. De Lisio” Institute of Behavioural Sciences
Pisa, Italy, EU
Annella-Maria Sciacchitano, MD
Pharmacologist,
Addiction treatment Centre (SerT), National Health System Local Unit,
Rovigo, Italy, EU
Lorenzo Somaini, MD
Clinical Pharmacologist
Addiction Treatment Centre (SerT), National Health System Local Unit,
Biella, Italy, EU
Emanuela Trogu, MD
Psychiatrist,
Addiction treatment Centre (SerT), National Health System Local Unit,
Cagliari, Italy, EU
Franco Vecchiet, MD
General Practitioner
National Health System,
Trieste, Italy, EU
Andrea Vendramin, MD
Professor of Pharmacology, University of Padua, Italy, EU
Director of Department of Addiction Medicine, National Health System
Local Unit,
Padua, Italy, EU
Sara Zazza, PhD
Psychologist,
Department of Addiction Medicine, National Health System Local Unit,
Torino, Italy, EU
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Preface
Several articles in magazines and symposium speeches try to answer the ques-
tion “What should the physician know?” I often feel doubts about what students
should be expected to know to pass a general pharmacology examination. I usu-
ally tell students they should think of themselves as athletes, while their professor
should be someone with such a deep knowledge of a discipline that he or she can
communicate it spontaneously. General practitioners remain athletes, with their
direct experience and constant updating enhancing their skills in the handling of
complex clinical syndromes and their depth of knowledge in managing specific
diseases and therapeutic approaches. This explains why I feel at a loss when they
ask me what the basis of pharmacological and medical knowledge should be, or
what it is essential to know about specific therapeutic issues. When speaking to
audiences of general practitioners, I am usually requested - when it’s a matter of
explaining what disorder a drug should be used against, what the proofs and the
terms of its effectiveness are, what its toxic effects are - to skip all the details and
foregrounds about the pharmacological basis of how and why it works, because
general practitioners are supposed not to bother much about such things. The
adoption of an evidence-based substance vs. substance approach has shifted the
focus of medical knowledge on to the statistical weight of clinical reports, where-
as mere consistency with pathophysiological dynamics is not considered reliable
as a predictor of effectiveness: in fact, clinical trials have often failed to confirm
a hypothesis of effectiveness founded solely on pathophysiological speculations
and open-label clinical reports. Nevertheless, the theoretical basis for the effective-
ness of pharmacological treatment has not become irrelevant, and may provide
warnings against risks that will not emerge from controlled clinical trials: that
happened with -coxib drugs and cerivastatine, which were quickly withdrawn
from the market due to surveillance warnings about toxicity - warnings which
had been anticipated by preclinical pathophysiological investigations, but had
not been expected on the basis of the results of later clinical trials. Often, it takes
pathophysiology to inspire a clinical study, which then gives positive spin-off in
return by providing evidence that deepens and enriches the level of knowledge
about the biological basis of therapeutics. Medical discipline results from a con-
tinuous exchange between biological research and clinical practice through the
channel of statistically weighted data.
6· ·7
Returning now to the question of “What should a physician know?”, the an-
swer should be translated into what each physician thinks he/she should know,
into their curiosity and professional liveliness, into their need to deepen their
knowledge. Both biologists and clinicians should avoid going into the fine detail
of technical aspects of their practice, unless questioned about it by an audience. In
any article, such details can be reported in a special section printed as a box kept
separate from the main text, or else, in case of an oral presentation, the speaker
may provide a reference list so that anyone can consult original data. Instead of
boring an audience with superfluous notions; it is a speaker’s interest and should
be within his/her grasp to know many other things that will only emerge in the
open discussion of scientific issues. Actually, “What should physicians know?”
should be viewed as an open-ended issue.
This book is written by clinicians and appeals to clinicians. It features a great
many pharmacological details about the pharmacological kinetics and dynamics
of anticraving treatment. The clinical issues are discussed by psychiatrists with
accuracy and by dedicating special attention to specific problems that emerge
during the course of treatment, ranging between ordinary ones and quite unex-
pected ones. For each situation authors discuss the possible causes and review the
different therapeutic strategies. The same issues seem to recur in different chap-
ters, with special regard to anticraving treatment and different ways to reach the
same solution from different viewpoints, while taking into account the variability
of drug-related clinical situations and the need to use a variety of starting points.
For instance, treating a pregnant narcotic addict requires specific skills, while
planning a treatment programme for jailed addicts calls for a specific knowledge
of the prison environment and related legal issues. Nowadays, since addiction
has become an endemic condition, it is expected to affect categories of individuals
with higher exposure to risk factors, which probably include several psychopatho-
logical syndromes. As a result, it is crucial to anticipate possible dual diagnosis
patterns, so as to be able to recognize them and handle such complex situations
through specific treatment approaches.
Several chapters deal with psychosocial issues related to the world of addiction,
with special reference to narcotics, both from a patient’s and from the physician’s
point of view. This subject is faced without resorting to a meaningless even if
politically correct approach. Drug addiction is presented as a psychiatric disorder
and a curable condition: treatment can provide complete control of its symptoms
by administering specific drugs in maintenance regimens of proved effectiveness.
Other interventions may be useful, in some cases crucial, as in any other chronic
disease, and comprise psychiatric and somatic treatments, individual counselling
to help patients cope with the family and work environment. Authors specify
the tasks of different staff members, whether medical or non-medical, who need
to know how to deal with the patient, while avoiding uncertainty about profes-
sional roles and hierarchical relationships. The present manual looms as an easy-
to-read volume, written by skilled professionals with technical competence and
an aversion for dogmatism.
Prof. Alessandro Tagliamonte
Professor of Pharmacology
University of Sienna
Italy, EU
8· ·9
Contents
INTRODUCTION
Definitions 11
1.1
I. Maremmani
Addiction Treatment: When will Medical Principles Matter ? 17
1.2
M. Pacini and I. Maremmani
Heroin Dependence 21
1.3
I. Maremmani and D. Popovic
Heroin Dependence: Theory of Different Levels of Intervention 31
1.4
I. Maremmani
Scientifically Based Ethical Principles in Dealing with Heroin Addicts 39
1.5
M. Pacini and I. Maremmani
Pharmacology and Neurochemistry of Methadone 43
1.6
A. Vendramin and A. M. Sciacchitano
Pharmacokinetics of Methadone 63
1.7
P.P. Pani
Neuroendocrinologic Effects of Methadone Treatment 69
1.8
G. Gerra
METHADONE TREATMENT
The History of Methadone Treatment 75
2.1
M. Pacini, A.G.I. Maremmani and I. Maremmani
Description:Medical Director of “Incontro” Therapeutic Community,. Pistoia, Italy, EU . sional
roles and hierarchical relationships. The present manual looms . pleasure in
order to avoid unwanted conse- quences is dicted subjects may seek help
even in the ab- sence of .. with treatment, so restoring a h
