Abstract
More patients with opioid addiction are receiving opioid agonist therapy (OAT) with methadone and buprenorphine. As a result, physicians will more frequently encounter patients receiving OAT who develop acutely painful conditions, requiring effective treatment strategies. Undertreatment of acute pain is suboptimal medical treatment, and patients receiving long-term OAT are at particular risk. This paper acknowledges the complex interplay among addictive disease, OAT, and acute pain management and describes 4 common misconceptions resulting in suboptimal treatment of acute pain. Clinical recommendations for providing analgesia for patients with acute pain who are receiving OAT are presented. Although challenging, acute pain in patients receiving this type of therapy can effectively be managed.
References
- 1.
Institute of Medicine . Federal Regulation of Methadone Treatment. Washington, DC: National Academy of Medicine; 1995:21-6. Google Scholar - 2.
Ball JC ,Ross A . The Effectiveness of Methadone Maintenance Treatment. New York: Springer-Verlag; 1991. Google Scholar - 3.
Metzger DS ,Woody GE ,McLellan AT ,O'Brien CP ,Druley P ,Navaline H ,et al . Human immunodeficiency virus seroconversion among intravenous drug users in- and out-of-treatment: an 18-month prospective follow-up. J Acquir Immune Defic Syndr. 1993;6:1049-56. [PMID: 8340896] MedlineGoogle Scholar - 4. Effective medical treatment of opiate addiction. National Consensus Development Panel on Effective Medical Treatment of Opiate Addiction. JAMA. 1998;280:1936-43. [PMID: 9851480] CrossrefMedlineGoogle Scholar
- 5.
O'Connor PG ,Fiellin DA . Pharmacologic treatment of heroin-dependent patients. Ann Intern Med. 2000;133:40-54. [PMID: 10877739] LinkGoogle Scholar - 6.
Cooper JR . Including narcotic addiction treatment in an office-based practice. JAMA. 1995;273:1619-20. [PMID: 7745777] CrossrefMedlineGoogle Scholar - 7.
Fiellin DA ,O'Connor PG . New federal initiatives to enhance the medical treatment of opioid dependence. Ann Intern Med. 2002;137:688-92. [PMID: 12379070] LinkGoogle Scholar - 8.
Krantz MJ ,Mehler PS . Treating opioid dependence. Growing implications for primary care. Arch Intern Med. 2004;164:277-88. [PMID: 14769623] CrossrefMedlineGoogle Scholar - 9.
Clark HW . Office-based practice and opioid-use disorders. N Engl J Med. 2003;349:928-30. [PMID: 12954740] CrossrefMedlineGoogle Scholar - 10.
Fiellin DA ,O'Connor PG . Clinical practice. Office-based treatment of opioid-dependent patients. N Engl J Med. 2002;347:817-23. [PMID: 12226153] CrossrefMedlineGoogle Scholar - 11.
Merrill JO . Policy progress for physician treatment of opiate addiction. J Gen Intern Med. 2002;17:361-8. [PMID: 12047733] CrossrefMedlineGoogle Scholar - 12. Quality improvement guidelines for the treatment of acute pain and cancer pain. American Pain Society Quality of Care Committee. JAMA. 1995;274:1874-80. [PMID: 7500539] CrossrefMedlineGoogle Scholar
- 13.
Federation of State Medical Boards of the United States, Inc . Model Guidelines for the Use of Controlled Substances for the Treatment of Pain. Euless, TX: Federation of State Medical Boards of the United States; 2003. Google Scholar - 14.
Gordon DB ,Dahl JL ,Miaskowski C ,McCarberg B ,Todd KH ,Paice JA ,et al . American Pain Society recommendations for improving the quality of acute and cancer pain management: American Pain Society Quality of Care Task Force. Arch Intern Med. 2005;165:1574-80. [PMID: 16043674] CrossrefMedlineGoogle Scholar - 15. The use of opioids for the treatment of chronic pain. A consensus statement from the American Academy of Pain Medicine and the American Pain Society. Clin J Pain. 1997;13:6-8. [PMID: 9084947] MedlineGoogle Scholar
- 16.
Joint Commission on Accreditation of Healthcare Organizations . Comprehensive Accreditation Manual for Hospitals: The Official Handbook. Oakbrook Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations; 1999. Google Scholar - 17.
Joint Commission on Accreditation of Healthcare Organizations . Joint Commission Focuses on Pain Management. Oakbrook Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations; 1999. Google Scholar - 18.
Marks RM ,Sachar EJ . Undertreatment of medical inpatients with narcotic analgesics. Ann Intern Med. 1973;78:173-81. [PMID: 4683747] LinkGoogle Scholar - 19.
Rupp T ,Delaney KA . Inadequate analgesia in emergency medicine. Ann Emerg Med. 2004;43:494-503. [PMID: 15039693] CrossrefMedlineGoogle Scholar - 20.
Cleeland CS ,Gonin R ,Hatfield AK ,Edmonson JH ,Blum RH ,Stewart JA ,et al . Pain and its treatment in outpatients with metastatic cancer. N Engl J Med. 1994;330:592-6. [PMID: 7508092] CrossrefMedlineGoogle Scholar - 21.
Breitbart W ,Rosenfeld BD ,Passik SD ,McDonald MV ,Thaler H ,Portenoy RK . The undertreatment of pain in ambulatory AIDS patients. Pain. 1996;65:243-9. [PMID: 8826513] CrossrefMedlineGoogle Scholar - 22.
Hill CS . When will adequate pain treatment be the norm? [Editorial]. JAMA. 1995;274:1881-2. [PMID: 7500540] CrossrefMedlineGoogle Scholar - 23.
Melzack R . The tragedy of needless pain. Sci Am. 1990;262:27-33. [PMID: 2296714] CrossrefMedlineGoogle Scholar - 24.
Carr DB ,Goudas LC . Acute pain. Lancet. 1999;353:2051-8. [PMID: 10376632] CrossrefMedlineGoogle Scholar - 25.
Savage SR . Opioid use in the management of chronic pain. Med Clin North Am. 1999;83:761-86. [PMID: 10386124] CrossrefMedlineGoogle Scholar - 26.
Lander J . Fallacies and phobias about addiction and pain. Br J Addict. 1990;85:803-9. [PMID: 1974156] CrossrefMedlineGoogle Scholar - 27.
Morgan JP . American opiophobia: customary underutilization of opioid analgesics. Adv Alcohol Subst Abuse. 1985;5:163-73. [PMID: 2870626] CrossrefMedlineGoogle Scholar - 28.
Scimeca MM ,Savage SR ,Portenoy R ,Lowinson J . Treatment of pain in methadone-maintained patients. Mt Sinai J Med. 2000;67:412-22. [PMID: 11064492] MedlineGoogle Scholar - 29.
Hoffman M ,Provatas A ,Lyver A ,Kanner R . Pain management in the opioid-addicted patient with cancer. Cancer. 1991;68:1121-2. [PMID: 1913484] CrossrefMedlineGoogle Scholar - 30.
Portenoy RK ,Dole V ,Joseph H ,Lowinson J ,Rice C ,Segal S ,et al . Pain management and chemical dependency. Evolving perspectives. JAMA. 1997;278:592-3. [PMID: 9268282] CrossrefMedlineGoogle Scholar - 31.
Savage SR . Addiction in the treatment of pain: significance, recognition, and management. J Pain Symptom Manage. 1993;8:265-78. [PMID: 7525743] CrossrefMedlineGoogle Scholar - 32.
Schnoll SH ,Weaver MF . Addiction and pain. Am J Addict. 2003;12Suppl 2 S27-35. [PMID: 12857661] CrossrefMedlineGoogle Scholar - 33.
Martin JE ,Inglis J . Pain tolerance and narcotic addiction. Br J Soc Clin Psychol. 1965;4:224-9. [PMID: 5872680] CrossrefMedlineGoogle Scholar - 34.
Compton P ,Gebhart G . The neurophysiology and pain and addiction.. In: Graham AW, Schultz TK, Mayo-Smith MF, Ries RK, Wilford BB, eds. Principles of Addiction Medicine. 3rd ed. Annapolis, MD: American Society of Addiction Medicine; 2003:1385-404. Google Scholar - 35.
Gardner EL . Brain reward mechanism.. In: Lowinson JH, Ruiz P, Millman RB, Langrod JG, eds. Substance Abuse: A Comprehensive Textbook. 3rd ed. Baltimore: Williams and Wilkins; 1997:51-84. Google Scholar - 36.
Zacny JP ,McKay MA ,Toledano AY ,Marks S ,Young CJ ,Klock PA ,et al . The effects of a cold-water immersion stressor on the reinforcing and subjective effects of fentanyl in healthy volunteers. Drug Alcohol Depend. 1996;42:133-42. [PMID: 8889412] CrossrefMedlineGoogle Scholar - 37.
Savage SR ,Schofferman J . Pharmacological therapies of pain in drug and alcohol addictions.. In: Miller N, Gold M, eds. Pharmacological Therapies for Drug and Alcohol Addictions. New York: Dekker; 1995:373-409. Google Scholar - 38.
Compton MA . Cold-pressor pain tolerance in opiate and cocaine abusers: correlates of drug type and use status. J Pain Symptom Manage. 1994;9:462-73. [PMID: 7822886] CrossrefMedlineGoogle Scholar - 39.
Compton P . Pain tolerance in opioid addicts on and off naltrexone pharmacotherapy: a pilot study. J Pain Symptom Manage. 1998;16:21-8. [PMID: 9707654] CrossrefMedlineGoogle Scholar - 40.
Prater CD ,Zylstra RG ,Miller KE . Successful pain management for the recovering addicted patient. Prim Care Companion J Clin Psychiatry. 2002;4:125-131. [PMID: 15014719] CrossrefMedlineGoogle Scholar - 41.
American Psychiatric Association . Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Text revision (DSM-IV-TR). Washington, DC: American Psychiatric Association; 2000. Google Scholar - 42.
Savage SR ,Joranson DE ,Covington EC ,Schnoll SH ,Heit HA ,Gilson AM . Definitions related to the medical use of opioids: evolution towards universal agreement. J Pain Symptom Manage. 2003;26:655-67. [PMID: 12850648] CrossrefMedlineGoogle Scholar - 43.
Eriator I . Narcotic analgesics for chronic pain management. Current Review of Pain. 1998;2:193-200. CrossrefGoogle Scholar - 44.
Vukmir RB . Drug seeking behavior. Am J Drug Alcohol Abuse. 2004;30:551-75. [PMID: 15540493] CrossrefMedlineGoogle Scholar - 45.
White JM . Pleasure into pain: the consequences of long-term opioid use. Addict Behav. 2004;29:1311-24. [PMID: 15345267] CrossrefMedlineGoogle Scholar - 46. Buprenorphine: an alternative to methadone. Med Lett Drugs Ther. 2003;45:13-5. [PMID: 12592214] MedlineGoogle Scholar
- 47.
Johnson RE ,Fudala PJ ,Payne R . Buprenorphine: considerations for pain management. J Pain Symptom Manage. 2005;29:297-326. [PMID: 15781180] CrossrefMedlineGoogle Scholar - 48.
Fishman SM ,Wilsey B ,Mahajan G ,Molina P . Methadone reincarnated: novel clinical applications with related concerns. Pain Med. 2002;3:339-48. [PMID: 15099239] CrossrefMedlineGoogle Scholar - 49.
Walsh SL ,Eissenberg T . The clinical pharmacology of buprenorphine: extrapolating from the laboratory to the clinic. Drug Alcohol Depend. 2003;70:S13-27. [PMID: 12738347] CrossrefMedlineGoogle Scholar - 50.
Gutstein HB ,Akil H . Opioid analgesics.. In: Hardman JG, Goodman Gilman A, Limbird LE, eds. The Pharmacological Basis of Therapeutics. 10th ed. New York: McGraw-Hill; 2001:569-620. Google Scholar - 51.
Inturrisi CE . Clinical pharmacology of opioids for pain. Clin J Pain. 2002;18:S3-13. [PMID: 12479250] CrossrefMedlineGoogle Scholar - 52.
McNicol E ,Horowicz-Mehler N ,Fisk RA ,Bennett K ,Gialeli-Goudas M ,Chew PW ,et al . Management of opioid side effects in cancer-related and chronic noncancer pain: a systematic review. J Pain. 2003;4:231-56. [PMID: 14622694] CrossrefMedlineGoogle Scholar - 53.
Houtsmuller EJ ,Walsh SL ,Schuh KJ ,Johnson RE ,Stitzer ML ,Bigelow GE . Dose-response analysis of opioid cross-tolerance and withdrawal suppression during LAAM maintenance. J Pharmacol Exp Ther. 1998;285:387-96. [PMID: 9580575] MedlineGoogle Scholar - 54.
Collett BJ . Opioid tolerance: the clinical perspective. Br J Anaesth. 1998;81:58-68. [PMID: 9771273] CrossrefMedlineGoogle Scholar - 55.
Doverty M ,Somogyi AA ,White JM ,Bochner F ,Beare CH ,Menelaou A ,et al . Methadone maintenance patients are cross-tolerant to the antinociceptive effects of morphine. Pain. 2001;93:155-63. [PMID: 11427327] CrossrefMedlineGoogle Scholar - 56.
Laulin JP ,Célèrier E ,Larcher A ,LeMoal M ,Simonnet G . Opiate tolerance to daily heroin administration: an apparent phenomenon associated with enhanced pain sensitivity. Neuroscience. 1999;89:631-6. [PMID: 10199599] CrossrefMedlineGoogle Scholar - 57.
Mao J . Opioid-induced abnormal pain sensitivity: implications in clinical opioid therapy. Pain. 2002;100:213-7. [PMID: 12467992] CrossrefMedlineGoogle Scholar - 58.
Streltzer J . Pain management in the opioid-dependent patient. Curr Psychiatry Rep. 2001;3:489-96. [PMID: 11707163] CrossrefMedlineGoogle Scholar - 59.
Compton P ,Charuvastra VC ,Kintaudi K ,Ling W . Pain responses in methadone-maintained opioid abusers. J Pain Symptom Manage. 2000;20:237-45. [PMID: 11027904] CrossrefMedlineGoogle Scholar - 60.
Ho A ,Dole VP . Pain perception in drug-free and in methadone-maintained human ex-addicts. Proc Soc Exp Biol Med. 1979;162:392-5. [PMID: 515020] CrossrefMedlineGoogle Scholar - 61.
Doverty M ,White JM ,Somogyi AA ,Bochner F ,Ali R ,Ling W . Hyperalgesic responses in methadone maintenance patients. Pain. 2001;90:91-6. [PMID: 11166974] CrossrefMedlineGoogle Scholar - 62.
Schall U ,Katta T ,Pries E ,Klöppel A ,Gastpar M . Pain perception of intravenous heroin users on maintenance therapy with levomethadone. Pharmacopsychiatry. 1996;29:176-9. [PMID: 8895942] CrossrefMedlineGoogle Scholar - 63.
Compton P ,Charuvastra VC ,Ling W . Pain intolerance in opioid-maintained former opiate addicts: effect of long-acting maintenance agent. Drug Alcohol Depend. 2001;63:139-46. [PMID: 11376918] CrossrefMedlineGoogle Scholar - 64.
Devillers JP ,Boisserie F ,Laulin JP ,Larcher A ,Simonnet G . Simultaneous activation of spinal antiopioid system (neuropeptide FF) and pain facilitatory circuitry by stimulation of opioid receptors in rats. Brain Res. 1995;700:173-81. [PMID: 8624708] CrossrefMedlineGoogle Scholar - 65.
Dunbar SA ,Pulai IJ . Repetitive opioid abstinence causes progressive hyperalgesia sensitive to N-methyl-D-aspartate receptor blockade in the rat. J Pharmacol Exp Ther. 1998;284:678-86. [PMID: 9454814] MedlineGoogle Scholar - 66.
Grilly DM ,Gowans GC . Acute morphine dependence: effects observed in shock and light discrimination tasks. Psychopharmacology (Berl). 1986;88:500-4. [PMID: 3085139] CrossrefMedlineGoogle Scholar - 67.
Devulder J ,Bohyn P ,Castille F ,DeLaat M ,Rolly G . A case of uncommon withdrawal symptoms after a short period of spinal morphine administration. Pain. 1996;64:589-91. [PMID: 8783325] CrossrefMedlineGoogle Scholar - 68.
Devulder J . Hyperalgesia induced by high-dose intrathecal sufentanil in neuropathic pain. J Neurosurg Anesthesiol. 1997;9:146-8. [PMID: 9100184] CrossrefMedlineGoogle Scholar - 69.
Laulin JP ,Larcher A ,Célèrier E ,LeMoal M ,Simonnet G . Long-lasting increased pain sensitivity in rat following exposure to heroin for the first time. Eur J Neurosci. 1998;10:782-5. [PMID: 9749743] CrossrefMedlineGoogle Scholar - 70.
Laulin JP ,Maurette P ,Corcuff JB ,Rivat C ,Chauvin M ,Simonnet G . The role of ketamine in preventing fentanyl-induced hyperalgesia and subsequent acute morphine tolerance. Anesth Analg. 2002;94:1263-9. [PMID: 11973202] CrossrefMedlineGoogle Scholar - 71.
Célèrier E ,Laulin JP ,Corcuff JB ,LeMoal M ,Simonnet G . Progressive enhancement of delayed hyperalgesia induced by repeated heroin administration: a sensitization process. J Neurosci. 2001;21:4074-80. [PMID: 11356895] CrossrefMedlineGoogle Scholar - 72.
Célèrier E ,Laulin J ,Larcher A ,LeMoal M ,Simonnet G . Evidence for opiate-activated NMDA processes masking opiate analgesia in rats. Brain Res. 1999;847:18-25. [PMID: 10564731] CrossrefMedlineGoogle Scholar - 73.
Célèrier E ,Rivat C ,Jun Y ,Laulin JP ,Larcher A ,Reynier P ,et al . Long-lasting hyperalgesia induced by fentanyl in rats: preventive effect of ketamine. Anesthesiology. 2000;92:465-72. [PMID: 10691234] CrossrefMedlineGoogle Scholar - 74.
Kantor TG ,Cantor R ,Tom E . A study of hospitalized surgical patients on methadone maintenance. Drug Alcohol Depend. 1980;6:163-73. [PMID: 6107237] CrossrefMedlineGoogle Scholar - 75.
Manfredi PL ,Gonzales GR ,Cheville AL ,Kornick C ,Payne R . Methadone analgesia in cancer pain patients on chronic methadone maintenance therapy. J Pain Symptom Manage. 2001;21:169-74. [PMID: 11226767] CrossrefMedlineGoogle Scholar - 76.
Karasz A ,Zallman L ,Berg K ,Gourevitch M ,Selwyn P ,Arnsten JH ,et al . The experience of chronic severe pain in patients undergoing methadone maintenance treatment. J Pain Symptom Manage. 2004;28:517-25. [PMID: 15504628] CrossrefMedlineGoogle Scholar - 77.
Jasinski DR . Tolerance and dependence to opiates. Acta Anaesthesiol Scand. 1997;41:184-6. [PMID: 9061104] CrossrefMedlineGoogle Scholar - 78.
Bruera E ,Macmillan K ,Hanson J ,MacDonald RN . The cognitive effects of the administration of narcotic analgesics in patients with cancer pain. Pain. 1989;39:13-6. [PMID: 2812850] CrossrefMedlineGoogle Scholar - 79.
Walsh T ,Baxter R ,Bowerman K ,Leber B . High-dose morphine and respiratory function in chronic cancer pain [Abstract]. Pain. 1981;S1:39. CrossrefGoogle Scholar - 80.
Hanks GW ,Twycross RG ,Lloyd JW . Unexpected complication of successful nerve block. Morphine induced respiratory depression precipitated by removal of severe pain. Anaesthesia. 1981;36:37-9. [PMID: 6894066] CrossrefMedlineGoogle Scholar - 81.
Dole VP ,Nyswander ME ,Kreek MJ . Narcotic blockade. Arch Intern Med. 1966;118:304-9. [PMID: 4162686] CrossrefMedlineGoogle Scholar - 82.
Jones BE ,Prada JA . Drug-seeking behavior during methadone maintenance. Psychopharmacologia. 1975;41:7-10. [PMID: 47638] CrossrefMedlineGoogle Scholar - 83.
Merrill JO ,Rhodes LA ,Deyo RA ,Marlatt GA ,Bradley KA . Mutual mistrust in the medical care of drug users: the keys to the “narc” cabinet. J Gen Intern Med. 2002;17:327-33. [PMID: 12047728] MedlineGoogle Scholar - 84.
Weissman DE ,Haddox JD . Opioid pseudoaddiction—an iatrogenic syndrome. Pain. 1989;36:363-6. [PMID: 2710565] CrossrefMedlineGoogle Scholar - 85.
Portenoy RK ,Foley KM . Chronic use of opioid analgesics in non-malignant pain: report of 38 cases. Pain. 1986;25:171-86. [PMID: 2873550] CrossrefMedlineGoogle Scholar - 86.
Evers GC . Pseudo-opioid-resistant pain. Support Care Cancer. 1997;5:457-60. [PMID: 9406359] CrossrefMedlineGoogle Scholar - 87.
Mao J ,Price DD ,Mayer DJ . Mechanisms of hyperalgesia and morphine tolerance: a current view of their possible interactions. Pain. 1995;62:259-74. [PMID: 8657426] CrossrefMedlineGoogle Scholar - 88.
Kehlet H ,Dahl JB . The value of “multimodal” or “balanced analgesia” in postoperative pain treatment. Anesth Analg. 1993;77:1048-56. [PMID: 8105724] MedlineGoogle Scholar - 89.
Botney M ,Fields HL . Amitriptyline potentiates morphine analgesia by a direct action on the central nervous system. Ann Neurol. 1983;13:160-4. [PMID: 6219612] CrossrefMedlineGoogle Scholar - 90.
Mitra S ,Sinatra RS . Perioperative management of acute pain in the opioid-dependent patient. Anesthesiology. 2004;101:212-27. [PMID: 15220793] CrossrefMedlineGoogle Scholar - 91.
O'Brien CP . Drug addiction and drug abuse.. In: Hardman JG, Goodman Gilman A, Limbird LE, eds. The Pharmacological Basis of Therapeutics. 10th ed. New York: McGraw-Hill; 2001:621-42. Google Scholar - 92.
Tilson HA ,Rech RH ,Stolman S . Hyperalgesia during withdrawal as a means of measuring the degree of dependence in morphine dependent rats. Psychopharmacologia. 1973;28:287-300. [PMID: 4734848] CrossrefMedlineGoogle Scholar - 93.
Paige D ,Proble L ,Watrous G ,Kaalaas-Sittig J ,Compton P . PCA use in cocaine using patients: a pilot study. American Journal of Pain Management. 1994;4:101-5. Google Scholar - 94.
Boyle RK . Intra- and postoperative anaesthetic management of an opioid addict undergoing caesarean section. Anaesth Intensive Care. 1991;19:276-9. [PMID: 2069256] CrossrefMedlineGoogle Scholar - 95.
Pasternak GW . Multiple opiate receptors: déjà vu all over again. Neuropharmacology. 2004;47Suppl 1 312-23. [PMID: 15464147] CrossrefMedlineGoogle Scholar - 96.
O'Connor PG ,Samet JH ,Stein MD . Management of hospitalized intravenous drug users: role of the internist. Am J Med. 1994;96:551-8. [PMID: 8017454] CrossrefMedlineGoogle Scholar - 97.
Fultz JM ,Senay EC . Guidelines for the management of hospitalized narcotics addicts. Ann Intern Med. 1975;82:815-8. [PMID: 1138596] LinkGoogle Scholar - 98. Center for Substance Abuse Treatment. Clinical Guideline for the Use of Buprenorphine in the Treatment of Opioid Addiction. Treatment Improvement Protocol (TIP) Series 40. DHHS publication no. (SMA) 04-3939. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2004. Google Scholar
- 99.
Edge WG ,Cooper GM ,Morgan M . Analgesic effects of sublingual buprenorphine. Anaesthesia. 1979;34:463-7. [PMID: 474948] CrossrefMedlineGoogle Scholar - 100.
Moa G ,Zetterström H . Sublingual buprenorphine as postoperative analgesic: a double-blind comparison with pethidine. Acta Anaesthesiol Scand. 1990;34:68-71. [PMID: 2309545] CrossrefMedlineGoogle Scholar - 101.
McCance-Katz EF . Office-based buprenorphine treatment for opioid-dependent patients. Harv Rev Psychiatry. 2004;12:321-38. [PMID: 15764468] CrossrefMedlineGoogle Scholar - 102.
Johnson RE ,Strain EC ,Amass L . Buprenorphine: how to use it right. Drug Alcohol Depend. 2003;70:S59-77. [PMID: 12738351] CrossrefMedlineGoogle Scholar - 103. Center for Substance Abuse Treatment. State Methadone Treatment Guidelines. Treatment Improvement Protocol (TIP) Series 1. DHHS publication no. (SMA) 93-1991. Rockville, MD: Substance Abuse and Mental Health Services Administration; 1993. Google Scholar
Author, Article, and Disclosure Information
Daniel P. Alford,
From Boston University Medical Center, Boston, Massachusetts, and University of California, Los Angeles, School of Nursing, Los Angeles, California.
Acknowledgments: The authors thank Jessica Richardson for editorial assistance.
Grant Support: Drs. Alford and Samet were supported by a grant from the National Institute on Drug Abuse (R25-DA-13582).
Disclosures: None disclosed.
Corresponding Author: Daniel P. Alford, MD, MPH, Clinical Addiction Research and Education (CARE) Unit, Boston Medical Center, 91 East Concord Street, Suite 200, Boston, MA 02118.
Current Author Addresses: Drs. Alford and Samet: Boston Medical Center, 91 East Concord Street, Suite 200, Boston, MA 02118.
Dr. Compton: University of California, Los Angeles, School of Nursing, Factor Building 4-246, Box 956918, Los Angeles, CA 90095-6918.
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