Efficacy of methadone maintenance treatment

Methadone doesn’t work for everyone. But the efficacy of methadone maintenance treatment has been documented since the 1990’s. Dr. Jana Burson tells us about the pharmacology of methadone, as well as the growing acceptance of methadone as valid treatment here.

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Poisons and medicine are oftentimes the same substance given with different intents.

Peter Mere Latham

Methadone maintenance treatment debate

The drug methadone sparks debate.  Discussions of methadone maintenance to treat opioid addiction cause disagreements even among addiction treatment professionals. This country, unlike European countries, has believed the only worthwhile recovery from addiction is drug-free recovery. Other countries long ago decided that reduction of harm done by addiction was a worthy goal in its own right, but the U.S. has been slow to embrace this view. We tend to have an “all or nothing” attitude.

Methadone addresses metabolic disorder

For a patient who feels chronically unwell off all opioids, methadone or buprenorphine may be the best course of treatment. Even in the 1960’s, Dr. Vincent Dole postulated that after taking opioids from outside sources, the body stops making its own opioids, called endorphins. These endorphins are required to feel normal. He conceptualized addiction as a metabolic disorder, with chronically reduced endorphin levels after prolonged use of opioids. Presently we have no way to measure endorphins, so this remains a theory.

Methadone replaces this lack of endorphins. Because it is an opioid, it stimulates the opioid receptors. Because it is long-acting, it can prevent withdrawal for twenty-four hours or more, in most patients. At the proper dose of methadone, patients should feel normal, not feel intoxicated, or high, and should not feel withdrawal symptoms. Likewise, doctors prescribe buprenorphine or Tramadol for opiate withdrawal.  However, Methadone gives opioid addicts a fairly steady level of opioid, compared to short-acting opioids usually used for intoxication.

Freed from the endless cycle of intoxication and withdrawal, addicts on methadone can participate in their own lives again. They can focus on the tasks of recovery such as learning how to stay clean and sober. They can participate in individual and group counseling, and purge their social networks of drug users. They can focus on securing employment and getting treatment for co-existing mental and physical health issues. Addicts are able to function normally on methadone.

Pharmacology of methadone

Using methadone and buprenorphine, which works by the same principle, to treat opioid addiction is not “like giving whiskey to an alcoholic,” as has incorrectly been asserted by opponents of medication assisted therapies. The valid difference lies in the unique pharmacology of methadone and buprenorphine. Opioid addicts can lead normal lives on either of these two medications, when they are properly dosed.

Patients take an oral dose of methadone once daily, instead of injecting or snorting an opioid every few hours, or searching for the next pill or balloon of heroin. Other than coming to the clinic each day for their dose, life can be normal for them. Most addicts enrolled in an opioid treatment program are able to save money, work, and participate in family life. They are also much more likely to get counseling, which is an essential element in the treatment of opioid addiction.

Good methadone clinics

Active addiction leads to chaotic and dangerous life styles (or death styles, as one patient said), and most people need time, support, and guidance to make positive changes. This necessary counseling should take place at the methadone clinic. A good clinic provides more than just medication.

Methadone as a valid treatment

Acceptance of methadone as a valid treatment option grew in the 1990’s, after reports from several government agencies highlighted its benefits. The General Accounting Office (GAO), after fully investigating methadone treatment, issued a report criticizing the low cap on methadone dosing. They saw the multiple studies that showed higher doses predicted better outcome in treatment. The GAO encouraged methadone clinics to avoid under- treatment with doses which were too low. (1)

In 1995, the Institute of Medicine (IOM) issued a report that recognized the benefits of methadone treatment, and criticized the over-regulation of methadone clinics. The IOM further recommended the federal regulations be modified, so more addicts could have access to effective treatment with methadone. (2)

In 1997, the National Institute of Health issued a consensus statement that emphasized that opioid addiction was a treatable medical disease, and that addiction is not caused by a failure of willpower. (3)

In 2001, a new national accreditation system was created, with the goal of transferring oversight of methadone clinics from the FDA to the Substance Abuse and Mental Health Services Administration (SAMHSA), since drug addiction was recognized as a treatable medical illness. This system, which operates today, started with the goal of standardizing and improving methadone treatment in the U.S. Under this new system, SAMHSA emphasizes best practice guidelines and accreditation standards, in an effort to encourage improved treatment, rather than relying on regulatory criteria.

Reference sources:
1. General Accounting Office, Methadone Maintenance: Some Treatment Programs are not Effective, Need Government Oversight, Report HRD-90-104, 1990
2. Richard A. Rettig and Adam Yarmolinsky, eds., Institute of Medicine, Federal Regulation of Methadone Treatment, (Washington, D.C., National Academy Press, 1995)
3. Effective Medical Treatment of Opiate Addiction. NIH Consensus Statement, Online 1997 Nov 17-19; [accessed 2009, July, 18]; 15(6):1-38
About the author
Jana Burson M.D. is board-certified in Internal medicine, and certified by the American Board of Addiction Medicine. After practicing primary care for many years, she became interested in the treatment of addiction. For the last six years, her practice has focused exclusively on Addiction Medicine. She has written a book about prescription pain pill addiction: "Pain Pill Addiction: Prescription for Hope." Also see Dr. Burson's blog here.
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