Opioid Replacement Treatment

What are the benefits of Methadone Maintenance Treatment (MMT)?

The benefits of methadone as a component of a comprehensive treatment program for opioid addiction have been validated by dozens of clinical studies and confirmed by numerous authorities in the addiction treatment field. These include:

• A stable maintenance dose of methadone does not make the patient feel either “high” or drowsy (somnolent), so the person can socialize, work or go to school, and generally carry on a normal life.
• Methadone can be taken orally once daily or in split doses, helping to limit exposure to injection-borne diseases like hepatitis and HIV.
• At adequate doses, methadone’s gradual, long-lasting effects eliminate opioid withdrawal and drug hunger or craving, unlike the rapid ups and downs of short-acting opioids which lead to strong desires for more drugs.
• Daily drug-seeking to “feed a habit” becomes unnecessary, and the euphoria-blocking effect of cross-tolerance makes other opioids undesirable.
• Once a stable dose is reached, there is little change in tolerance to the therapeutic effects of methadone, so it does not take increasingly more of the medication to achieve the same results.
• When properly prescribed by an experienced practitioner, methadone has a favorable safety profile with minimal side effects.

How is success in MMT measured?

The broad goal of methadone maintenance treatment (MMT) is to help opioid-dependent persons cease their use of heroin and/or other abused opioids and lead more stable, productive lives in recovery. However, good MMT programs strive to help patients achieve many more specific objectives, including:

• Patients are encouraged to abstain from all addictive substances – including alcohol, cocaine and other stimulants, marijuana, and others
• The misuse of prescribed medications is discouraged
• Patients are expected to decrease and avoid criminal behavior of any sort, and MMT program staff help resolve current difficulties with the criminal justice system
• MMT medical staff help patients attend to health matters, especially those possibly related to past drug use, such as HIV/AIDS, hepatitis, and tuberculosis
• MMT staff identify and treat mental health problems that might have contributed to or resulted from substance abuse
• Patient educational development and employability are stressed and assistance is provided
• Program staff work with patients and their families to resolve relationship difficulties, child care concerns, and housing problems

Attending to all of those issues is a tall order and usually takes months or years to accomplish. Addiction recovery in MMT is an ongoing process, often moving forward in small steps at a time. Methadone, itself, is only a medication that helps get the hard work toward recovery started; the rest depends on the motivation of the patient in cooperating with program staff and making the many life changes necessary for rehabilitation.

Does MMT just substitute one addictive drug (such as, heroin) with another (methadone)?

Methadone Maintenance Treatment (MMT) is a form of drug replacement therapy, using a medication (methadone) to overcome the compulsive need for other opioid drugs (such as heroin or other abused opioids). While the person is, indeed, physiologically dependent on methadone, the pharmacologic actions of methadone are quite different from addictive opioid agents – methadone is not a mere substitute.

An analogy is how prescribed insulin is used as replacement or “substitution” therapy in an individual with diabetes. The person remains “dependent” on insulin; however, a chronic disease condition is kept under control and effectively managed by the administration of a licensed, prescribed medication.

With adequate methadone, addictive behaviors cease. Persons on methadone may not be “drug-free”; however, they are being helped to overcome the debilitating influence of illicit opioids and lead more healthy, normal lives in recovery. It also is important to note that the behavioral hallmarks of true addiction – such as unsuccessful efforts to cut down on drug abuse, the endless search for more drug, avoidance of obligations in pursuit of drug, and use despite personal harm – are eliminated during MMT.

The many specific benefits of MMT overshadow any concerns about continued reliance on the use of medication for treating the chronic, relapsing disease of opioid addiction. Some people have discounted methadone as being nothing but a “crutch” for persons who are too weak to become drug free. However, as Vincent Dole, MD – a developer of MMT – once commented, “There’s absolutely nothing wrong with using crutches if it helps the person get back on his feet and move forward in addiction recovery. We need more crutches like that.”

Is heroin the only drug for which methadone maintenance is a treatment?

Methadone, given on a daily basis as part of a comprehensive recovery program, may be useful for treating addiction to any opioid drug. This class of drugs includes those made from the opium poppy, like heroin, morphine, or opium itself – these are often called “opiates.” Other opioids are made synthetically, like oxycodone (Percocet ®), hydromorphone (Dilaudid ®), hydrocodone (Vicodin ®), codeine, and others.

All of the opioids work on similar areas in the brain, called mu-opioid receptors. Methadone, which is a synthetic and very long-lasting opioid, works in those same brain areas, occupying the receptors so completely that it blocks the effects of other opioids. In this way, methadone prevents opioid withdrawal symptoms and reduces drug craving. To do this, methadone only has to be taken once a day, every day – called methadone maintenance treatment or MMT – and, at the proper dose, it does not make the person feel “high” or drugged. So, the person can lead a more normal and healthier life.

MMT is not intended for treating addiction to non-opioid drugs, such as cocaine, alcohol, marijuana, or others. In fact, taking those other substances of abuse while in methadone treatment can hinder the person’s progress in recovery. However, research has demonstrated that the majority of patients receiving adequate methadone doses decrease or eliminate their use of other psychoactive substances. Counseling and psychosocial therapy, including participation in 12-Step groups, provide important treatments for dealing with the problems of other drug and alcohol abuse. Long-term retention in MMT also is vital for allowing enough time for such approaches to exert their beneficial effects.

How long does a patient need to stay in MMT?

Time in treatment is a critical factor for ongoing addiction recovery. Typically, methadone-maintained patients must attend a treatment program each day to receive their oral dose of methadone; however, stable and compliant patients are usually allowed to eventually take home a number of doses, thus reducing their clinic visits. Appropriate psychosocial therapy and other support services are integral components of ongoing MMT.

Credible and authoritative sources have concluded that patients treated for fewer than 3 months in MMT generally show little or no improvement. Studies have routinely demonstrated reductions in illicit opioid use of up to 80% or more after several months, with the greatest reductions for patients who remain in treatment more than a year. Patients often require MMT indefinitely, as would be expected with any chronic medical condition. Once a patient has been stabilized on MMT, withdrawal from methadone carries substantial risks. Virtually all who abandon MMT and do not pursue further recovery treatment of some sort eventually relapse and potentially overdose.

How can I get off of methadone?

Since methadone creates a physical dependency on the drug, stopping it abruptly (e.g., “cold turkey”) would lead to intense withdrawal symptoms and drug craving. The accepted way of discontinuing methadone is called medically supervised withdrawal (MSW). Its main objective is to relieve or prevent uncomfortable withdrawal symptoms and craving while the patient gradually achieves an opioid-free state.

During MSW – sometimes erroneously called “detox” – the daily dose of methadone is decreased by small amounts over time, taking many weeks or months. This should only be done under the care of a doctor, and only after discussing the reasons for wanting to discontinue methadone and considering ongoing treatment alternatives. Relatively few persons who withdraw from methadone or other opioids, and who do not continue in some form of addiction treatment program, stay drug-free for any extended length of time.

A more rapid form of withdrawal, taking only hours, requires that the person first be put completely to sleep (under general anesthesia) in order to tolerate the otherwise severe withdrawal symptoms, and then certain medications are used to purge the body of methadone or other opioids. This method is expensive and still undergoing study in terms of its safety and long-lasting benefits. Many, if not most, persons undergoing this treatment have eventually returned to illicit-opioid abuse (relapsed).

Why is methadone harder to “kick” than heroin?

Surveys have found that substantial numbers of MMT patients are concerned about difficulties in withdrawing from methadone, claiming it is harder to “kick” than heroin. However, this is a persistent myth that was long ago disproved.

A blind comparison study years ago at a federal facility for addiction treatment in Lexington, Kentucky, found that withdrawal symptoms actually were less severe in patients maintained on methadone than in those taking equivalent doses of short-acting opioids like heroin. Because it is long-acting, withdrawal from methadone does last much longer than withdrawal from short-acting opioids. Therefore, a person who has experienced “cold turkey” withdrawal separately from heroin and methadone might say that “kicking” methadone was worse – because it lasted longer. This is one way the myth might have started and it ignores the fact that methadone withdrawal should never be done “cold turkey” to begin with.

However, gradual withdrawal from methadone, when properly done under medical supervision, can be virtually free of discomfort. On the other hand, patients who try to withdraw from methadone by themselves, on their own time and dose schedule, almost always experience undue discomfort and fail.

Also, some patients forget that the reason they came into MMT was because they could not stay away from opioid drugs on their own. When they decide to leave MMT and find they cannot just stop taking methadone, they blame the methadone rather than the heroin or other opioids that deranged their brain chemistry in the first place. For many former illicit-opioid-addicted persons, methadone is a lifelong medication necessary for stabilizing brain function, much like a person with diabetes needs insulin every day to live a normal life.

Are there any alternative treatments for Opiate Dependence ?

YES, Buprenorphine was approved by the FDA in 2002 as the first medication for treating opioid dependence available for use in office-based settings through implementation of DATA 2000 and through opioid treatment programs. Multiple studies have shown that Buprenorphine is a safe and effective alternative to methadone for managing opioid dependence, and is a particularly effective option for patients with prior, not current, methadone experience.

Prevention

How does an agency become a certified provider for Prevention services?

Community providers who are interested in becoming certified for prevention services should contact the Office of Prevention Services to obtain basic information on the standards and credentials required for certification.

Is it a requirement to be a certified agency to receive funding from the Division of Mental Health and Substance Abuse Services?

Yes. Other funding sources within the state currently do not require certification.

What kinds of Prevention programs are funded by the Division of Mental Health and Substance Abuse Services?

The majority of prevention programs currently funded are Universal prevention programs. Future programs will need to assess the needs for Selective and Indicated programs. Communities may also need Environmental strategies and applicable policy and practice changes to alleviate substance abuse issues.

Where are Prevention programs located?

A prevention directory of certified providers may be obtained through the MHSA receptionist or the Office of Prevention Services.

How may I obtain Prevention materials (brochures, videos, government publications, paraphernalia) on Prevention topics?

Two clearinghouses within the state are available for the public and community providers. The North Regional Information Clearinghouse in Anniston 256-237-8131 and the Drug Education Council 251-478-7855 in Mobile is the South Regional Information Clearinghouse. These services are offered at no cost to the consumer.

How does an individual become credentialed in Prevention?

ADA is the primary contact for individuals to attain Prevention credentials. The contact number is 256-796-4490. Additionally, individuals are required to have twenty (20) hours of continuing education per year.

How may I obtain information on National resources for Prevention activities?

The following websites will be of help: www.samhsa.gov, www.health.org, www.nasadad.org, www.whitehousedrugpolicy.gov, www.stopalcoholabuse.org,
www.drugabuse.gov

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