Methadone highlighted as safe and effective treatment for opioid addiction

THE LANCET

SCIENCE AND MEDICINE

HIV-1 researchers talk cautiously of a good year HIV-1-positive patients treated for 10 months who had low or undetectable amounts of viral RNA. However, peripheral blood CD4 cells from these patients contained proviral DNA that could be activated to produce viruses, some of which were resistant to protease inhibitors. Proviral DNA has also been found in follicular dendritic cells—ie, there is a latent reservoir for HIV-1 that is unaffected by drug treatment. In the past year, many chemokine co-receptors for HIV-1 have been described, and their expression patterns at least partly explain phenomena such as resistance to HIV-1 infection and non-progression. Seven chemokine receptors are now known to be involved in HIV-1 cell entry. Some of these receptors can mediate viral entry indepenHIV-1 drug resistance reported in Brazil dent of the CD4 receptor. A study released last week by the State of São Indeed, for some virus–cell Paulo, Brazil, revealed that 30% of AIDS combinations, the CD4 patients treated with a combination of two receptor may be the real coreverse-transcriptase inhibitors and one receptor. Recent results also protease inhibitor had to switch to another shed light onto the origin of therapeutic regimen because they developed HIV-1-related brain damage drug resistance. Of the 100 patients studied, and dementia. Astrocytes, 47% had an improvement in their health. The microglia, and neurons all disease did not progress in 32% of the patients have chemokine receptors, but 21% of them got worse or died. Drug which help HIV-1 enter the resistance may have arisen because of late central nervous system. onset of treatment or lack of adherence to the

he gloomy world of AIDS has metamorphosed during the past year. Triple therapy, the growing number of antiviral drugs, and breakthroughs in basic research have imbued the field with new hopes, new challenges, and new questions. But last week, the main message from the second annual AIDS conference at the Institute of Human Virology in Baltimore (MD, USA) was one of cautiousness. In particular, predictions that extended antiviral therapy might eradicate HIV-1 from infected people were dismissed as more mathematics than biology. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases (Bethesda, MD, USA) presented new data on 13

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correct administration of drugs. Claudio Csillag

News in brief Doctors to be vaccine guinea pigs The International Association of Physicians in AIDS Care announced on Sept 22 that about 50 doctors have volunteered for vaccination with an attenuated HIV-1 vaccine. IAPAC will meet US National Institutes of Health and Food and Drug Administration officials to discuss the trial. Peanut allergy transfer French doctors report a case of peanut allergy transfer to a transplant patient. 3 months after receiving a liver and kidney transplant, the patient reported a skin rash and laryngeal dyspnoea after eating peanuts. The authors speculate that allergen-specific donor lymphocytes were transferred to the recipient in the liver (N Engl J Med 1997; 337: 822–24). Mutations and heart attacks People with one mutant copy of the lipoprotein lipase gene have a fivefold greater risk of heart attack than people with two normal copies (Circulation 1997; 96: 1737–44). Individuals with one mutant gene have high blood triglycerides and low high-density-lipoprotein cholesterol concentrations.

Inger Atterstam

Methadone highlighted as safe and effective treatment for opioid addiction between dependence and tolerance peaking at the 3rd European and thus normalcy. Retention rates Methadone Conference in maintenance programmes, he (Ljubljana, Slovenia; Sept 17–20), noted, are five times better if dosing Robert Newman (New York, USA) is adequate. If patients say they need vociferously lamented the lack of more methadone, they adequate dosing in many probably do, added methadone treatment Thomas Payte (San programmes, largely, he Antonio, TX, USA). said, because of the Other drugs can interprejudice, ignorance, and fere with methadone fear that surrounds this blood values and some method of substitution. patients are poor or Why, continued Marc rapid metabolisers. Shinderman (Chicago, Concerns that methIL, USA), should the adone causes death principles of medicine Old habits die hard in maintenance prothat are applied to any grammes were not borne out by data other specialty be abandoned when it presented by Sandra Sunjic (Dulwich comes to opioid addiction? A physiHill, NSW, Australia). The 242 cian would not undertreat epilepsy, methadone-related deaths in the he said, so to do so in methadone NSW programme between 1990 and maintenance is “an abdication of our 1995 were mostly just that—related, responsibility as physicians”. A not causal. Polydrug use was serum concentration of at least 400 involved in 89% of cases. ng/mL achieves the middle ground Science Photo Library

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Vol 350 • September 27, 1997

Of the newer drugs to replace methadone, the partial agonist buprenorphine was hailed as a rising star. Licensed only in France, this drug taken sublingually has low dependence potential and produces little respiratory depression. However, retention rates seem disappointing. Preliminary data from a study comparing buprenorphine and methadone, said Harald Eder (Vienna, Austria), showed a much higher drop-out rate by week 18 in the buprenorphine group (60%) than in the methadone group (20%), although Paul Fudala (Pennsylvania, PA, USA) suggested that the dose, 8 mg per day, may not have been high enough. Gabrielle Fischer (Vienna, Austria) reported that, in pregnancy, buprenorphine does not lead to the neonatal abstinence syndrome that is seen with methadone. Pia Pini

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