Substance Abuse Treatment Modalities: Literature Review

Methadone

Methadone is a synthetic narcotic analgesic. The other major synthetic narcotic is meperidine (Demerol). Narcotic analgesics derived from opium are morphine, heroin (diacetylmorphine), and codeine.

Use of methadone for treatment of heroin addiction was pioneered by Vincent Dole and Marie Nyswander in the 1960s. They had a theory that heroin addicts developed a biological adaptation to opiates such that they needed to maintain some level of opiate in their body to feel “normal.” It should be noted that they did not mean an adaptation such as when a person becomes dependent on alcohol. When a person who is dependent on alcohol has completed withdrawal, the person is essentially “normal”. However, Dole and Nyswander hypothesized that heroin addicts, even after withdrawal, would never feel “normal” unless they resumed having some level of opiate in their system.

Methadone treatment, therefore, was developed as a substitute for heroin, and was intended as a maintenance medication, much as insulin is used to treat diabetes or lithium chloride is used for certain mood disorders. Methadone has a longer half-life than heroin and only needs to be taken once a day, usually orally. Methadone is not an exact substitute for heroin, however. Its analgesic effect is far less strong than that of heroin, and it competes with heroin for access to sites of action in the brain. This latter feature means that if methadone is present in a sufficiently high dose, it will occupy many of the sites of action, and if heroin is consumed the heroin will have little effect (because there will be few receptor sites for it to stimulate). Thus, an individual on methadone would have little incentive to also use heroin.

Typically methadone treatment is accompanied by behavioural counselling. Multiple evaluations have found methadone to be extremely effective in certain regards: it reduces users' consumption of illicit drugs, it reduces criminal activity, and it helps users become more socially productive (e.g., they typically can maintain employment) and psychologically stable (e.g., they typically can maintain a family life). Some less positive evaluations can be found in the literature, but they generally can be explained in terms of methadone dosage. That is, it has been found that the dose typically needs to be at least 60 mg per day in order for methadone to be fully effective; and at lesser doses, users are likely to supplement the methadone with heroin. At this time some individuals have successfully used methadone maintenance for more than 30 years.

An important issue regarding methadone is that the treatment is surrounded by moral debate in that much of the public considers it reprehensible to offer heroin addicts a medically prescribed substitute drug, despite the proven benefits of doing so. Another issue is that many methadone programs are poorly planned and managed, in that addicts are treated with disrespect and often subject to arbitrary rules with penalties for transgressions that include being dismissed from the program. This combination of factors has resulted in two major problems for methadone treatment. First, in many programs patients are typically given doses of methadone below the 60 mg level. Second, many programs have goals of methadone withdrawal rather than maintenance.

Methadone withdrawal is a two-stage procedure. The first stage is switching the person from heroin to methadone. Once stabilized, the second stage is withdrawing the person from the methadone. It is the latter stage that has proved problematic. Detoxification from heroin has a poor track record, with relapse rates usually more than 90%. This was one of the main reasons why Dole and Nyswander hypothesized that heroin addiction leads to a permanent biological alteration. Detoxification from methadone has a slightly better, but far from outstanding, record. Early studies found relapse rates on the order of 85%. Later studies have found that a critical factor determining the likelihood of success is the reason for detoxification. For individuals who have become socially stable, have stopped using other drugs and are seeking to be drug free, the probability of successful detoxification is high. For example, in a study reported by Stimmel, Goldberg, Rotkopf and Cohen (1977), 83% who met these criteria were drug free over a follow-up period averaging slightly over two years. Of individuals who did not meet these criteria, only 14% to 21% were drug free. However, only 17% of all patients met the criteria. In other words, although few patients become fully stabilized on methadone and seek to become totally drug free, those who achieve that status have an excellent chance of detoxifying successfully. For the great majority of patients, however, the chance of successful detoxification is small. Moreover, recent research has suggested that individuals who have poor outcomes of detoxification often develop an organic mood syndrome characterized by dysphoria, insomnia, loss of appetite and somatic complaints. This condition would probably increase the probability of the individual returning to the use of heroin.

Methadone, as a controlled substance, is subject to both federal and provincial law. Provincial regulations can vary considerably. Use of methadone in North American programs is somewhat different than in certain other countries in that (a) methadone in North America is typically reserved for those who are severely dependent on heroin - they usually have to pass a naltrexone test (a drug that precipitates opiate withdrawals) to demonstrate they are sufficiently dependent, and (b) withdrawal rather than maintenance is often the goal of treatment. In many programs in Great Britain, Europe and Australia a so-called low threshold approach is used (making methadone available to less severely addicted cases as well) and maintenance is socially accepted.

Part of psychosocial counselling is to provide stabilized patients with “carries” on the weekend, meaning that they can take home one or two days' additional doses rather than having to come to the program daily. “Carries” are usually contingent upon complying with program rules and having urine tests free of evidence that other illicit drugs had been consumed.

Alternatives to methadone are currently receiving much attention. LAAM is a longer acting form of methadone that needs to be taken only two or three times a week. Buphenorphine is an agonist-antagonist to heroin that also has a longer period of action. Buphenorphine has less of an analgesic effect than methadone and it also opposes the actions of heroin such that the individual will not experience a euphoric effect if heroin is used.

The longer lasting actions of these drugs offer great advantages for treatment programs and their clients in that a given program can treat a larger caseload, and clients do not need to appear at the program on a daily basis. The latter is a particular advantage to the long-term stabilized client who does not need intensive counselling or help.

References for Methadone:

Ball, J. C., & Ross, A. (1991), The effectiveness of methadone maintenance treatment: Patients, programs, services, and outcome, New York: Springer-Verlag.

Dole, V. P., & Joseph, H. J. (1974), “Long-term outcome of patients treated with methadone maintenance”, Annals of the New York Academy of Sciences, 311, 181-189.

Dole, V. P., & Nyswander, M. E. (1976), “Methadone maintenance treatment: A ten year perspective”, Journal of the American Medical Association, 235, 2117-2120.

Gerstein, D. R., & Harwood, H.J. (Eds.) (1990), Treating Drug Problems, Vol. 1.Washington, D.C.: National Academy Press.

Kanof, P. D., Aronson, M. J., & Ness, R. (1993), “Organic mood syndrome associated with detoxification from methadone maintenance”, American Journal of Psychiatry, 150, 423-428.

Stimmel, B., Goldberg, J., Cohen, M,. & Rotkopf, E. (1978), “Detoxification from methadone maintenance: Risk factors associated with relapse to narcotic use”, Annals of the New York Academy of Sciences, 311, 173-180.

---