Methadone Maintenance Programs

Methadone is an analgesic (painkiller) that was first created in Germany during World War II. Its actions on the body are similar to those of morphine, which, like heroin, is an opiate, or a drug made from the opium poppy. Methadone was approved by the U.S. Food and Drug Administration in August 1947 for use in the treatment of pain.

Methadone maintenance treatment for heroin addiction was developed in the mid-1960s by doctors Vincent Dole and Marie Nyswander. These doctors were responding to concerns about epidemics of heroin addiction, related health problems, deaths (especially among young people 15 to 35), and a high relapse rate among addicts. Methadone was able to ease the withdrawal symptoms of heroin addicts. Later, scientists determined that methadone could be used in long-term maintenance treatment. In other words, methadone use is maintained, or kept going continuously, rather stopped after a limited period. Through this ongoing treatment, addicts are able to stay off heroin.

At first, many addiction specialists hoped that methadone could be used to help addicts quit heroin and then stop taking the methadone. However, research eventually indicated that less than 20 percent would be able to stop taking methadone and remain drug- free. Dole and Nyswander held the view that there was something unique about heroin addiction that made it especially difficult for patients to remain drug-free. Dole began to suspect that long-term use of heroin may do damage to the brain's receptors . It is not currently known how to reverse these permanent changes in brain function. New brain imaging technology holds the promise of better understanding and perhaps more effective treatment. In the meantime, it appears that methadone can correct but not cure a severe addiction. Studies show that as much as 80 percent of heroin addicts who discontinue methadone treatment relapse to drug use. This is true even of patients who have received counseling and therapy to change their lifestyles.

Benefits of Methadone Treatment

Methadone provides a safe and effective way to eliminate drug craving , withdrawal, and drug-seeking behavior (when addicts spend most of their time and energy finding drugs). As a result, methadone can help free patients from their drug habit, allowing them to lead productive lives. When combined with educational, medical, and counseling services, methadone can enable patients to discontinue or reduce heroin use and the criminal activity that often goes along with it. Their physical and mental well-being improves, they become responsible family members, and they are able to get and keep a job or pursue an education.

Another important aspect of long-term methadone use is that it does not result in any physical or psychological impairment, or damage, of any kind. Specifically, there is no impairment of balance, co- ordination, mental abilities, eye-hand coordination, depth perception, or psychomotor functioning. This means that people on methadone maintenance can perform the actions necessary for their jobs or other daily activities. Recently, some people receiving methadone treatment have been identified through workplace drug testing and have been threatened with negative consequences. Supporters of methadone treatment have worked to protect these people from what they view as discrimination.

Common Misunderstandings

Despite three decades of research showing the value of methadone maintenance treatment, this treatment has been a source of conflict and disagreement among treatment providers, the public, and government officials. This ongoing controversy is not simply a difference of opinion among informed parties. Instead, the debate about methadone usually involves several common misunderstandings about the drug and its uses. Much of the uneasiness about methadone stems from the idea that it is "just substituting one drug for another." Although this is technically correct, an explanation of how methadone treatment works shows why this is in fact a misunderstanding.

How Treatment Works. Methadone treatment is a therapy in which one drug (heroin) is replaced with another (methadone). Heroin is a short-acting drug that is usually injected. Methadone is a long-acting drug that a person takes by mouth. Methadone can prevent heroin withdrawal symptoms. Because of its long action (24–36 hours), it allows most patients to receive a dose and function in a stable manner. Without methadone, they would go through the four-hour cycles of euphoria (a feeling of intense well-being) and withdrawal that are typical of heroin use. Heroin addicts on methadone treatment can in fact become well-functioning individuals, meaning that they may be able to hold down a jobs, improve relationships, and manage money more effectively.

The Importance of the Right Dose. A stable blood level of methadone must be maintained at all times for the treatment to produce good results. Unfortunately, state or local regulations have often placed restrictions on methadone doses without regard to medical criteria. This means that doctors are not allowed to prescribe a dose higher than a set limit, even if they feel that the patient needs a higher dose for specific medical reasons. A common policy has been to give as little of the drug as possible, rather than to give the amount needed to accomplish the goal of reducing withdrawal symptoms and helping a person remain free of heroin. This policy was based partly on the (unproven) belief that lower doses would make it easier to discontinue methadone. It has been common to have dose maximums of 40 milligrams (mg) per day. It is now known that the effective range is between 60 and 120 mg per day for most patients, with some needing less than 60 and others a great deal more than 120 mg. Getting the right dose is of crucial importance in ending drug use and keeping addicts in treatment.

The low-dose policy has had troubling results. Patients on low doses who complain that "my dose isn't holding me"—or preventing their cravings—may be dismissed from treatment programs because treatment providers believe these people are simply looking for more drugs, just as they had once devoted all their energies to looking for heroin. When these patients then supplement the methadone dose with heroin, the patient may be seen as lacking the will to quit, or the treatment may be seen as ineffective.

Dependence versus Addiction. A second objection to methadone treatment is that methadone, like heroin, is addicting. Critics question the idea of giving an addicting drug as a form of treatment. But there is a difference between dependence and addiction. Like the heroin it replaces, methadone leads to physical dependence. Unlike heroin, it does not lead to addiction. Addiction is different from dependence because addiction involves behavior that is out of control, driven by compulsions , and that continues no matter what the negative consequences might be (such as poor health, the loss of a job or housing, or the chance of being caught and punished for illegal activity). Several prescription drugs produce dependence but not addiction in this way. For example, patients given morphine to treat long-term pain will develop dependence on morphine. But once their condition improves and medication is stopped, they do not seek more of the drug—they have not become addicted.

Physical dependence must be considered when treating any patient, whether for a medical condition or addiction. For specialists in the field of addiction, the key is to determine whether the improvements in the person's functioning and quality of life outweigh the costs of physical dependence. Many providers of treatment for heroin addicts believe that the benefits do in fact outweigh the costs.

Methadone and a Drug High. Another criticism is the belief that "methadone keeps you high." This belief reflects a misunderstanding about the effects of a properly adjusted dose. When a person begins methadone treatment, it takes time for a doctor to determine the right dose. The goal is to stabilize the patient on a consistent dose that will prevent the craving for heroin. At first, the dose may be large enough to produce some effects that the user experiences as a high. Once stabilized, however, most patients experience little or no effects of the drug—that is, they do not feel high. Heroin addicts often say that they seek methadone to avoid getting sick (to prevent withdrawal effects), not to get high.

Methadone and Other Drug Use

Heroin addicts are often addicted to other drugs as well, such as alcohol and cocaine. Methadone patients may continue to abuse these drugs while being treated for heroin abuse. It is important to remember that methadone cannot prevent other kinds of drug use. However, it does make many patients more willing to try other kinds of treatment. Patients must come to the clinic at least once a week, and in most cases more often, to get their methadone dose. As a result, the patient is exposed to educational presentations and materials and to counseling efforts that are part of individual treatment plans. In fact, methadone maintenance programs require that the patient get counseling and learn about addictions. By participating in these aspects of the program, addicts may be encouraged to stop their use of cocaine and alcohol.

HIV/AIDS and Hepatitis C

Methadone treatment has played an important role in reducing the spread of HIV/AIDS. This success has lessened some of the criticisms of methadone programs. Methadone clinics offer AIDS prevention and education services, screening, testing, and counseling. Methadone patients often discuss life issues with counselors, who may be able to persuade patients to practice safe sex and to avoid other high-risk behaviors.

The hepatitis C virus (HCV), which affects liver function, has emerged as a major problem among addicts receiving treatment at clinics. Among those with HIV, the rate of simultaneous infection with HCV is high. Methadone maintenance provides an organized system in which the patient can be supervised for good medical care, informed of emerging treatments, and educated about health practices to reduce the burden on the liver.

What the Future Holds

Methadone maintenance has been effective at reducing illegal drug use and guiding addicts toward productive lives. A scientific review of studies in the middle to late 1990s concluded that the treatment's effectiveness has been reduced by two factors: (1) too much government regulation, and (2) negative opinions held by the public and policy makers.

Attitudes toward methadone treatment are changing. The federal government is preparing to permit patients to receive treatment in doctor's offices affiliated with clinics rather than only in clinics. This will help patients by bringing them into the mainstream of medical practice, rather than separating them in addiction clinics. Regulations that control how clinics operate are being eased, and clinics have more freedom to determine the best treatments for individual patients. Slowly, patients are coming forward to serve as examples of success and to be role models for others.

Researchers have developed other medications to treat heroin addiction, particularly LAAM and buprenorphine , expanding the possibilities for effective treatment. As researchers continue to investigate addiction and treatment, they will consider two important questions: (1) Could a condition that existed before heroin use make some patients more likely to become severely addicted than others? (2) Can long-term addicts ever recover normal functioning without methadone maintenance therapy?