He shoots Dimedrol. He misses the vein, an abscess forms. You know what that is. He rots. When there is Dimedrol involved, one cannot function properly, one cannot work, one will just be high. Stigmatization of people who use Dimedrol by other prisoners and members of the informal prison leadership compounded stigmatization of people who accessed MMT.
Because MMT was run by the formal prison authority as opposed to the heroin trade which is run by the informal prison leadership , prisoners receiving MMT were viewed by other prisoners as being aligned with the formal prison authority and viewed suspiciously by the informal prison leaders and other prisoners.
Dimedrol is also banned by formal prison administrators, who have their own punitive approach to people in prison using Dimedrol:. If the guards catch a patient with Dimedrol, a report is immediately drafted…and the patient is locked up in isolation. People on MMT were perceived as being especially vulnerable because they can lose their status in the prison hierarchy. In a prison setting where PWID are vulnerable to exploitation and informal and formal leadership systems compete for control, both MMT and Dimedrol acquire meaning that influence their use and distribution [ 22 ].
These explanations borrowed heavily from a shared sentiment that methadone was harmful and not to be trusted. As one interviewer recorded in his fieldnotes:. Dimedrol is not used on its own and methadone and Dimedrol are often conflated because of how they are used [ 22 ]. The harms of Dimedrol use were attributed to methadone and used as an argument for phasing out methadone:.
It actually has a lot to do with methadone because, without methadone, for example, why the hell would anyone need this shit? It would be better if they were giving heroin that way [as they distribute methadone]. And they would shoot up less Dimedrol. This explicit linking of Dimedrol injection with methadone treatment was evident also in interviews with prison administrators and other non-prisoner participants who acknowledged the difficulty of intervening on Dimedrol injection within Kyrgyz prisons that take a mainly punitive approach to Dimedrol possession.
In this study, we found that Dimedrol injection is a potentially serious drug-related harm among people receiving methadone treatment in Kyrgyz prisons. This study has implications for the further quantitative investigation of antihistamine polysubstance use as well as sociological inquiry into how the relations between different drugs affect the way drugs are used. In the context of a regional rise in HIV incidence primarily associated with injection drug use, our findings suggest that Dimedrol injecting can no longer be ignored as a public health problem.
Dimedrol injection and its health and social consequences were repeatedly raised as areas of concern for MMT implementation by prisoner and non-prisoner participants. In this study, prisoner and non-prisoner participants, including prison administrators and medical staff members, described illicit injection of crushed Dimedrol tablets as a serious and potentially widespread behavioral health concern affecting people receiving methadone treatment in prison.
Participant accounts contain graphic descriptions of disfiguring injuries and behavioral changes consistent with possible effects of diphenhydramine injection described elsewhere [ 17 , 18 , 19 , 20 , 21 ]. Participants pointed to these physical and behavioral changes as evidence that methadone was harmful.
Heroin, on the other hand, remained untainted by Dimedrol and therefore is a more favorable substance among prisoners adhering to the rules of criminal subculture.
Prison administrators, medical staff, and community members recognize and have requested support to address the issue but acknowledge long-standing difficulties in controlling the supply of drugs within prison that have contributed to Dimedrol injection and its harmful health consequences in prisons. The narrative that conflates MMT with Dimedrol injecting and its harmful effects [ 22 ] is especially damaging to public health efforts to implement MMT as an intervention for HIV prevention and harm reduction.
Methadone has been a global mainstay of treatment for opioid use disorder for over 40 years. A dose—response curve indicates a minimal dose of 30 mg to prevent symptoms of opioid withdrawal and craving and to effect positive health outcomes, and doses must be individually titrated to reduce the risk of over-sedation and respiratory depression [ 29 ]. Numerous prior studies have suggested that when methadone dosing is inadequate to prevent cravings, polysubstance use prevails and contributes to negative health outcomes [ 30 ].
One possible explanation for Dimedrol injection reported here is that patients are experiencing suboptimal methadone dosing and that prison medical staff should be doing more to screen for concurrent drug use and monitor drug craving in patients receiving methadone. Individuals who use Dimedrol concurrently with MMT often do so intentionally seeking a high, suggesting MMT in the absence of other supportive services or interventions insufficiently manages symptoms of substance use disorders, including impulsivity.
Although people on MMT in Kyrgyz prisons are excluded from heroin distribution, they may use Dimedrol along with MMT to achieve euphoria, combat the boredom inherent to life in prison [ 31 ], or self-medicate mood disorders like depression or anxiety [ 32 ]. Although these motivations were scarcely mentioned by our key informants, they offer a compelling potential explanation for Dimedrol injection in this context and underscore the need for psychiatric care in these settings.
One way to curb Dimedrol injecting is by attempting to reduce supply, for example by intervening to reduce delivery of Dimedrol from the outside and creating a climate of health and wellness [ 8 ]. If we are to apply a purely harm reduction lens to the problem of Dimedrol injecting in Kyrgyz prisons, however, then the solution is not to attempt to banish Dimedrol entirely but rather to expand NSP access to support safe injecting practices because many MMT patients are not offered NSP.
It is unclear whether crushed Dimedrol tablets, even if mixed with sterile water and injected with sterile equipment, would ever be safe to inject given the seeming toxicity of the substance to veins.
Liquid Dimedrol is not widely available in Kyrgyz prisons and might be more difficult for people to conceal, though theoretically potentially safer to inject. PWID in Kyrgyz prisons need low barrier access to urgent medical services for evaluation and management of skin and soft tissue infections, voluntary and confidential HIV testing, and education about the potential physical and psychological harms of Dimedrol injecting.
None of these interventions will be successful without the buy-in of formal and informal prison leaders, so a major challenge now is to develop and implement these interventions in a way that is meaningful and sustainable given the particularities of criminal subculture in Kyrgyz prisons.
Structural interventions are required given how Dimedrol is situated as part of the informal governing and day-to-day survival of people in prison. This study has some limitations. Most prisoner participants described the behaviors of other prisoners, rather than their own behaviors, which may reflect their lack of comfort in speaking about behaviors that could be construed as deviant or criminal in a prison setting.
Further studies are needed to quantify the frequency of Dimedrol injection and its sequelae, in Kyrgyz prisons and elsewhere. It is likely that antihistamine injecting is more prevalent than reflected in the existing literature because it is legal though banned in prisons and, unlike narcotics, obtained without a prescription. Although some disclosure about illicit behaviors by people in the prison environment may have been limited by fear of surveillance, we conducted interviews with people in prison at every level of the social hierarchy and people outside of prison in the community where there are fewer potential repercussions of disclosure.
It is unclear how findings would have differed if the interviews were not audio-recorded. Key informant participants and stakeholders were purposively recruited, which may have unintentionally introduced selection bias and limit generalizability to other prisoners or PWID in the EECA, though that was not the intention of this qualitative study [ 33 ].
Finally, most prisoner participants in this study were incarcerated in a male prison. Their views and experiences may differ from those of people incarcerated in a female prison. Some persons receiving methadone treatment in Kyrgyz prisons also may inject crushed Dimedrol tablets, a non-prescription antihistamine that is banned in prison, to achieve a state of euphoria.
Dimedrol injection is asserted to cause devastating physical and mental health effects, including psychosis and necrotic injury. The visible wounds of Dimedrol injection figure prominently in narratives about methadone treatment inside prison. Prisoners who use heroin, which is tightly controlled according to the rules of criminal subculture, do not use Dimedrol, lending heroin a more positive image within prisoner society.
The persistence of Dimedrol injection within these settings is a potentially serious threat to individual health and harm reduction within Kyrgyz prisons and elsewhere in EECA region. Walmsley R. Intersecting epidemics of HIV, HCV, and syphilis among soon-to-be released prisoners in Kyrgyzstan: implications for prevention and treatment. Int J Drug Policy. Drug injection within prison in Kyrgyzstan: elevated HIV risk and implications for scaling up opioid agonist treatments. Int J Prison Health.
A coordinated approach to tackling the drug situation in Kyrgyz prisons. United Nations Office on Drugs and Crime. Policy brief: HIV prevention, treatment and care in prisons and other closed settings: a comprehensive package of interventions; Evaluation of opioid substitution therapy in Kyrgyzstan; Uptake of needle and syringe program services in the Kyrgyz Republic: key barriers and facilitators.
Drug Alcohol Depend. Article PubMed Google Scholar. Zelichenko A. Rapid assessment in prisons. Google Scholar. Assessment of the medication assisted therapy program in the Kyrgyz Republic; Sharma A, Hamelin BA. Curr Drug Metab. Wang Z, Woolverton WL. Super-additive interaction of the reinforcing effects of cocaine and H1-antihistamines in rhesus monkeys.
Pharmacol Biochem Behav. Wadley C, Stillie GD. Pentazocine Talwin and tripelennamine Pyribenzamine : a new drug abuse combination or just a revival? Int J Addict. Promethazine misuse among methadone maintenance patients and community-based injection drug users. J Addict Med. Promethazine use among chronic pain patients.
Drug preparation, injection, and sharing practices in Tajikistan: a qualitative study in Kulob and Khorog. Subst Abuse Treat Prev Policy. Teplinskaya I. A life in free fall: a Russian drug addict's story updated 17 November Turaeva M, Engmann B. Outcome measures are described in Table 2. Adverse events to injected prescription heroin have been described in Swiss heroin clinics [ 35 ], however further information comparing the adverse profile of injected diamorphine, oral and injected methadone in chronic addict populations is needed to better characterise the safety profile of these medications.
Adverse events may occur as a result of the drug e. Indeed, anecdotal reports suggest that some patients experience considerable adverse reactions e. RIOTT will examine adverse events between the three treatment groups over time. There are also potential concerns regarding the cardio-respiratory effects of injectable opioids. Previous studies examining self-administration of injectable heroin and methadone have identified significant hypoxia in some patients [ 36 , 37 ].
However, it is unclear to what extent the risk of hypoxia is influenced by treatment conditions e. There have also been recent concerns regarding the use of high dose oral and injected methadone and prolongation of QTc intervals, a condition associated with cardiac arrythmias such as torsade de pointes and sudden death [ 38 , 39 ]. It remains unclear whether injected methadone poses a greater risk of QTc prolongation than equivalent doses of oral methadone.
The acute effects of injected diamorphine upon ECG changes have not been previously reported. To address these concerns, indices of respiratory and cardiac function are examined in relation to the drugs used methadone versus diamorphine , route of administration oral, IV and IM , and dose, compared to pre-randomisation baseline measures. The prescription and supervised injection of diamorphine and methadone allows the opportunity to study the physiological, subjective and cognitive-performance effects of these drugs.
Despite widespread use of injected heroin in many societies, there is to date remarkably little published literature about the impact of injected heroin or methadone upon these parameters. Another aspect of safety of this treatment approach is that of 'community safety'.
One of the major issues facing those providing drug treatment services is the possible community backlash when such services are proposed within a local community. The establishment of a supervised injecting clinic raises potential concerns for the local community.
Examples may include fears of local residents and businesses regarding the congregation of drug users regularly attending the clinic; or concerns regarding intoxicated clients being a nuisance to the local community. As a part of the overall RIOTT, a community impact evaluation will be conducted to: a investigate the impact on the local community of supervised injectable maintenance clinic; b document the expectations, fears and experience of the local community; and c compare and contrast the methods used by different services for addressing community interaction.
The study design incorporates a blend of epidemiological and social research methodologies in order to gather data from a number of complimentary sources. The economic evaluation will take a broad cost perspective, including costs borne by the health, social, voluntary and criminal justice sectors, and costs to the economy in the form of productivity losses. Detailed information on the resources associated with the three treatment interventions are collected from the relevant clinics and include staff time, equipment, study medications, dispensing services and the treatment of adverse events.
Data on the use of all other services including health, social and voluntary sector services , days off work due to illness, criminal justice sector contacts and crimes committed are collected using a service use schedule, based on one designed at the University of York for the economic evaluation of alcohol and drug interventions and successfully applied to evaluations of brief interventions [ 40 ]. Self-report data are collected at research interviews at baseline and at the 3 and 6 month follow-up points.
Cost-effectiveness will be explored in terms of illicit heroin use, the primary outcome measure, and in terms of quality adjusted life years, using the EQ-5D measure of health-related quality of life see Table 2. A service-user researcher CH employed through a service user-organisation, the Alliance, conducts structured and semi-structured interviews with subjects throughout the follow-up period to gain information on expectations of, and satisfaction with treatment see Table 2.
Semi-structured interviews will also explore the broader experience of prescribed and non-prescribed heroin use, exploring the contextual influence of the clinical setting itself in the construction of individual's experiences of heroin use. It is expected that interviews with a service user researcher may lend greater validity to subject responses when examining issues such as treatment goals, perceptions about illicit heroin use and treatment. Quantitative data will be recorded by hand in Case Record Forms, coded, and entered into a database using the Statistical Package for Social Science software by a researcher.
Data will be analyzed on an intention-to-treat basis. Continuous outcomes collected at 3 time points baseline, 3 months and 6 months follow-ups , will be modelled using repeated measurement with mixed models approach to examine the differences between treatment and control groups and the time course. Correlated responses will be dealt with by covariance structures. Endpoints that are coded as categorical data will be treated as multivariate binary responses in order to fit the repeated measurements.
Odds ratios will be used to present differences in treatment retention between the control and IOT groups. Semi-structured interviews collecting qualitative data are tape recorded with subject consent and transcribed, with all identifying information removed from the transcripts. Data is analysed in hard copy form, using qualitative thematic analysis [ 41 ]. Despite IOT being part of the British treatment system, there have been few studies examining the safety and effectiveness of this approach, particularly of injectable methadone treatment, which comprises the majority of IOT in this country.
The primary aim of RIOTT is to compare the safety, efficacy and cost effectiveness of injectable methadone and diamorphine treatment delivered under supervised conditions , to optimised oral methadone treatment, in methadone patients who regularly inject illicit heroin. Such research should better inform clinicians and policy makers as to how to respond to this patient group, and to inform decision making as to whether additional resources should be directed to IOT, or to enhancing the capacity for oral methadone treatment to be delivered under optimised conditions.
The establishment of RIOTT also enables a variety of 'nested' studies examining a range of issues regarding injectable heroin and methadone.
Some of these studies have been briefly discussed, such as projects examining the cardio-respiratory effects of these drugs in chronic opiate dependent individuals. Other projects being examined include cognitive-performance effects of injectable opioids compared to oral methadone, and pharmaco-genetic research examining responses to opioid treatment.
Despite the widespread proliferation of heroin use across the world, and despite reports of widespread misuse of methadone by injection [ 42 ], there has been remarkably little laboratory research examining the pharmacological effects of these drugs at high doses in chronic opiate users. Such research may lead to a better understanding of the mechanisms behind heroin-related harms such as cognitive impairment and overdose.
A key point in embarking on another RCT of injectable heroin treatment relates to the extent to which there is a sufficient evidence base currently available to scientifically 'prove' the efficacy of heroin prescribing — in short — do we need more heroin trials? Underlying this is the question 'how much evidence is required in order to scientifically establish the efficacy and safety of a particular treatment'? The experience of substitution opiate treatment methadone, LAAM, buprenorphine suggests that considerable and unequivocal evidence is required in order to defend such treatments against politicised critics — be they politicians, academics, service providers, local community or ex drug user groups — much more so than in most other areas of medicine.
This applies to an even greater extent with the highly controversial issue of injectable opioid prescribing. A particularly strong evidence base will be a minimum requirement in establishing IOT as an available option — the findings of two or three RCTs alone are unlikely to convince sceptics of such a contentious treatment paradigm.
The most recent systematic Cochrane review of heroin prescribing suggests that differences in study design limit our capacity to draw conclusions on the available published trials in this area. The completion and dissemination of the various international trials in Germany, Spain, Canada and Britain is required in order to establish this evidence base, particularly as we should not pre-empt the findings of such studies in assuming that they will all show similar results.
Should the broad safety and efficacy of IOT be established through the various trials underway internationally, it will enable researchers to address the next 'level' of clinical-research questions.
This may include issues around the availability of take-away doses of injectables, the selection of which opioids should be prioritised, and whether patients can be successfully transitioned from injecting to non-injecting e.
We should also recognise that, as with the expansion of methadone and buprenorphine treatment internationally over the past 20 years, any expansion of IOT will often be preceded by calls for 'local' research that addresses local concerns and regulatory requirements. Rather research is required to establish its role within the treatment system after over a decade of decline, and at a time where health systems are requiring a greater evidence base of efficacy and cost-effectiveness.
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Volume 1: Report and Proceedings of the Committee. Potential roles in drug treatment: Full guidance report. Darke S: Self-report among injecting drug users: A review. Musshoff F, Trafkowski J, Madea B: Validated assay for the determination of markers of illicit heroin in urine samples for the control of patients in a heroin prescription program. Metrebian N, Shanahan W, Stimson GV, Small C: Prescribing drug of choice to opiate dependent drug users: a comparison of clients receiving heroin with those receiving injectable methadone at a West London drug clinic.
Article Google Scholar. Clin Pharmacol Ther. Gourlay GK, Cherry DA, Cousins MJ: A comparative study of the efficacy and pharmacokinetics of oral methadone and morphine in the treatment of severe pain in patients with cancer. Acta Anaesth Scand Supp. Wolff K: Characterization of methadone overdose: clinical considerations and the scientific evidence. Ther Drug Monit.
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Acta Psychiatr Scand. Eur Addict Res. Download references. The RIOTT group consists of clinicians and researchers who have contributed to the development or implementation of the research project, but have not contributed sufficient to be authors of this paper. You can also search for this author in PubMed Google Scholar.
Correspondence to Nicholas Lintzeris. These three authors have equally contributed to the drafting of this report. Your doctor will decide when and whether to change your dose.
If you miss a dose of methadone, take it as soon as you remember unless it is closer to the time of your next dose. Do not double your next dose or take more than what is prescribed.
Avoid drinking alcohol, using sedatives, or other opioid pain medications such as codeine, hydrocodone, oxycodone, or morphine , or using illegal drugs while you are taking methadone. They may increase adverse effects e. Keep in mind that some cough syrups may contain opioid pain medication. Discuss all medications with your doctor and pharmacist prior to taking methadone. If an overdose occurs, call your doctor or You may need urgent medical care.
You may also contact the poison control center at You should always call after giving someone naloxone to treat an overdose.
Ask your provider if prescription naloxone is right for you or your family member to have available. Methadone causes physical dependency when taken daily for a long period of time. This means that you may have withdrawal symptoms if methadone is stopped abruptly.
Talk to your provider before stopping methadone. These medications should be taken exactly as prescribed. It is very dangerous to take methadone with benzodiazepines if you do not have a prescription.
Using methadone with antipsychotics, tricyclic antidepressants, and certain heart medications may increase the risk of developing irregular heart rhythms. Your pharmacist or doctor will help you to determine if other medications you take can interfere with the effects of methadone. Patients taking methadone may develop heart-related effects that can lead to irregular heartbeats, which can cause sudden death.
Your doctor will want to ask you questions about heart disease and monitor your heart regularly during treatment. Methadone may cause serious, life-threatening, or fatal decrease in breathing. Your doctor may monitor you closely for breathing, especially when beginning treatment with methadone or when increasing your dose. This medication has an opiate drug in it.
The FDA has found that the use of opiate drugs with benzodiazepine drugs or other sedating medications can result in serious adverse reactions including slowed or difficult breathing and death. Benzodiazepine drugs include drugs like alprazolam, clonazepam, and lorazepam.
Benzodiazepine drugs are used to treat health problems like anxiety, trouble sleeping, or seizures. Patients taking opioids with benzodiazepines, other sedating medications, or alcohol, and caregivers of these patients, should seek immediate medical attention if they start to experience unusual dizziness or lightheadedness, extreme sleepiness, slowed or difficulty breathing, or unresponsiveness.
Last Updated: January This information is being provided as a community outreach effort of the College of Psychiatric and Neurologic Pharmacists. This information is for educational and informational purposes only and is not medical advice. This information contains a summary of important points and is not an exhaustive review of information about the medication.
Always seek the advice of a physician or other qualified medical professional with any questions you may have regarding medications or medical conditions.
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