Methadone: Revolutionizing Opioid Addiction Treatment

Methadone revolutionized the treatment of opioid addiction in the 1960s by providing the first effective, practical, and legal alternative to detoxification for the treatment of opioid addiction.

Detoxification is inadequate on its own to provide lasting sobriety because most addicts eventually relapse without additional treatment. Medication-assisted treatment with methadone was the first of several medications to effectively protect from relapse. Treatment with methadone also reshaped our understanding of opioid addiction as illness because there was now a medical treatment that substantially aided in recovery.

Prior to the 1960s, the stigma of opioid addiction was pervasive and unfortunately continues to this day. Prior to the introduction

of methadone, addiction was viewed not as an illness but as a weakness of character or a moral failure. It was illegal to be an opioid addict. African-Americans were unfairly blamed for the
surge in crime stemming from opioid addiction (http://theatln.tc/1Enby2a).
Treatment with methadone as a substitute for heroin was the start of our recognition of addiction as a treatable medical illness. Medication-assisted treatment with methadone remains a proven, popular and successful treatment endorsed by most healthcare providers.
The new official name is Opioid Treatment Program (OTP), but the principles behind the treatment of opioid addiction with methadone have not changed since its introduction more than fifty years ago. You can read more about the history of medication-assisted treatment with methadone at http://bit.ly/1RnTJH2.
METHADONE AS A REPLACEMENT MEDICATION
Methadone serves as a substitute for the abused opioids, such as heroin or any of the painkillers. This option represents a significant advancement. Addicts can easily convert to methadone without having to go through a painful detoxification because methadone is itself an opioid. The patient switches from the abused opioid to methadone in a medically supervised outpatient clinic called an Opioid Treatment Program. Previously, these were known as Methadone Treatment Programs.
The physician then gradually adjusts the methadone dose to reduce or eliminate withdrawal symptoms and cravings and minimize side effects. Methadone is continued while the addict acquires skills through individual and group substance abuse therapy to learn how to remain sober after completing treatment.
TREATMENT CONSIDERATIONS
A member of the treatment team completes an intake to assess suitability for maintenance treatment with methadone. The assessment includes a detailed physical health, mental health, substance abuse, social, family, and legal history. A physical examination and drug test are part of the admission process.
Methadone doses vary widely, but typically range from 60 mg to 150 mg daily, depending on how slowly or quickly the liver metabolizes methadone. A strict requirement is for patients to meet periodically with healthcare providers, attend substance abuse group therapy, and attend AA or NA. The clinic may require proof of attendance at a 12-step support program.
Patients come to the clinic once daily to receive a dose of methadone from a nurse who witnesses the swallowing of the methadone. Methadone’s long residence time in the body makes it ideal for once-daily dosing. Patients can receive take-home doses for several days at a time if they meet specific requirements. Examples include consistent clinic attendance, having a job or going to school, abstaining from illegal substances and alcohol, and consistent attendance at AA or NA.
Methadone’s long residence time in the body can also be a negative. Methadone can slow breathing, increase sedation, or cause an arrhythmia (Chapter 13). Patients can also get a “high” from methadone. Some patients complain of fatigue, so driving or operating machinery may be impaired.
Infractions, such as frequent positive drug or alcohol tests, missing doses, missing clinic visits, not attending group meetings, not attending AA or NA, failure to pay clinic fees, or disrupting clinic operations can lead to an “administrative discharge” (http://1.usa.gov/1M1lt22).
TIME TO REMAIN ON METHADONE
While on methadone, substance abuse therapy and NA or AA are critical components of the recovery process. Addicts must learn why they became addicted and what they will need to do to remain substance-free after completing treatment. There is no set time to stay on methadone, but recommendations are for a minimum of twelve months. Patients with a more problematic drug abuse history may benefit from longer-term or indefinite treatment with methadone. The physician and patient jointly decide when or if to discontinue methadone. However, unless committed by the court for treatment with methadone, patients can choose to end treatment at any time.
When coming off of methadone, many OTPs slowly decrease the daily dose on a “blind schedule” so that the patient is unaware of the actual declining daily dose of methadone. Often, coming off of methadone takes several months.
POSITIVE AND NEGATIVE CONSIDERATIONS
As with all treatments, there are positive and negative considerations:
Positive Considerations
• Methadone plays a vital role in the treatment of opioid addiction.
• Medication-assisted treatment with methadone is an evidence-based treatment proven to save lives and to reduce relapses, transmission of disease, and crime. Its value, now measured with more than fifty years of clinical experience, is unprecedented.
• It is fairly easy to transition from street opiods to methadone without having to experience extreme withdrawal symptoms.
• Outcomes are better when patients remain on the methadone for at least twelve months.
• Medication-assisted treatment with methadone serves the needs of the most severely addicted individuals who benefit from the tight structuring (overseeing) OTPs provide.
• Dispensing methadone daily improves compliance and eliminates diversion.
• Frequent drug and alcohol testing helps to reduce the abuse of other drugs or alcohol or catch a relapse early.
• Methadone can serve two roles: pain management and medication-assisted treatment of opioid addiction. However, methadone dispensed from an OTP cannot be used primarily to manage pain, although it may additionally serve that purpose.
Negative Considerations
• Methadone is very addictive.

For some, once on methadone, alway on methadone.

• Methadone is a powerful opioid. Even when used correctly under the direction of a physician, some patients report getting “high” and “nodding off” (falling asleep) after taking their dose. After all, it’s the same drug abused on the street (called “street methadone”).

• Constipation is a common if not universal side effect.

• Sedation, weight gain, difficulty with urination, and decreased sex drive are frequent side effects. Some patients complain they sleep both day and night. Patients should not drive or operate machinary after taking methadone until the side effects wear off.

• Abuse is possible despite the tight structuring of the OTP. An individual can supplement with “street methadone” to generate more of a “high” without detection. This increases the risk of an adverse event, such as an overdose or arrhythmia.

• Taking too much methadone or combining methadone with other drugs or medications, such as another opioid, benzodiazepines, or alcohol, can be fatal due to the consequences of respiratory failure, sedation, seizures, or an arrhythmia (http://bit.ly/1GIBN4m).

• Because methadone can generate a “high” under legal dosing conditions, patients may be reluctant to discontinue methadone when they can fully do

so.
• Patients with cardiac problems or liver disease may not be suitable for treatment with methadone.
• The cost of treatment varies from state to state and location to location. Insurance coverage is spotty. Self-pay is around $15–$30 per day or on average about $600 per month.
• Time demands (daily visits) can reduce opportunities for school or employment.
• Opioid Treatment Programs may have waiting lists. Addicts waiting for treatment are at an
increased risk of an overdose death (http://1.usa.gov/1LO6Y0v).
• In some locations where OTPs are far from home, patients travel many hours each day for their daily methadone dose and then return home. The time demands for travel could compromise the ability to work or go to school. Occasionally, patients use the longer drive times as an excuse for not undertaking these valuable and necessary activities.
• Methadone clinics are not infrequently plagued by sudden onset patient deaths. These can be due to cardiac arrythmias, falling asleep at the wheel of the car, adding “street methadone” to the clinic dose, or mixing methadone with substances such as another poioid, a benzodiazepine, or alcohol.
• Medication-assisted treatment with methadone carries stigma. Federal regulations require that addicts receive methadone only in segregated facilities (OTPs). This requirement implies that addicts are possibly less worthy, dangerous, or inferior to patients with other illnesses, such as hypertension or diabetes. This premise is wrong and does great harm by continuing to stigmatize addiction.
FINDING A OPIOID TREATMENT PROGRAM (METHADONE TREATMENT PROGRAM)
Opioid Treatment Programs may have a waiting list. Here are websites to search for an OTP:
• SAMHSA Opioid Treatment Program Directory (http://1.usa.gov/1QPRBJT)
• Methadone US (http://bit.ly/1LNkAtk)
• Opioid Addiction and Treatment Resource (http://bit.ly/1d25t3U)
You can read more about medication-assisted treatment with methadone at http://bit.ly/1VLunUY.