The American Society of Addiction Medicine (ASAM) has developed criteria to be used in the consideration of treatment for any type of substance use disorder that results in the development of physical dependence. These criteria include:
- Consider the potential for intoxication and/or withdrawal.
- Consider all biomedical complications and conditions.
- Consider all emotional, cognitive, and/or behavioral conditions and complications.
- Consider the readiness to change of the individual.
- Consider the potential for relapse or other problems.
- Consider the individual’s living environment.
Opioid dependence as a result of the abuse of opiate drugs is a continuing problem in the United States. The development of an opioid use disorder is often complicated by the development of severe physical dependence on the drug of abuse. The development of physical dependence consists of displaying both the syndromes of tolerance (needing more of a drug to produce effects once achieved at lower amounts) and withdrawal (the appearance of negative physical and emotional symptoms once the drug is discontinued). Because individuals who chronically abuse opioids and develop opioid use disorders develop significant physical dependence on these drugs, they experience severe difficulty attempting to discontinue their use.
Given the above considerations by ASAM, medication-assisted treatment (MAT) has been developed to address specific withdrawal symptoms for drugs like opioids.
MAT consists of the use of medications or a combination of medicines and behavioral interventions to address specific aspects of substance use disorders.
The American Psychiatric Association (APA) has outlined effective strategies for managing dependence on opioid drugs (tolerance and withdrawal):
- Opioid replacement therapy with specific medications that includes a gradual taper
- Abrupt discontinuation of an opioid drug with use of medications, such as clonidine or other drugs, to block withdrawal symptoms
- The use of combinations of drugs, such as naltrexone and clonidine, to address the withdrawal process
Opioid replacement therapy consists of using a specific medication that attaches to the receptors in the brain that the opioid drug of abuse targets during the early phases of recovery. This strategy eliminates or reduces the withdrawal syndrome significantly, and physicians then attempt to slowly taper the opioid replacement medication to allow the individual’s system to slowly adjust to decreasing doses of the drug. Over a specified period of time, the drug is tapered and then finally discontinued, and the individual can continue their substance use disorder recovery. Methadone is a drug that has long been used as an opioid replacement drug.
What Is Methadone?
Methadone is a synthetic or manmade opioid drug that can be used in the treatment of opioid dependence, especially for drugs like heroin. The use of methadone for the treatment of opioid dependence goes as far back as the 1950s. Its use became popular in the 1960s to address what was described as the “heroin epidemic.” In the early 1970s, an estimated 25,000 patients were enrolled in methadone maintenance treatment programs. The drug’s prescription became restricted to registered doctors and pharmacies as a result of the Narcotic Treatment Act of 1974 due to escalating cases of methadone abuse. Methadone is also used in the treatment of chronic pain in some individuals.
There are several reasons to explain why someone would elect to become involved in methadone replacement therapy or methadone maintenance therapy. The major reason to use methadone is to avoid withdrawal symptoms associated with discontinuing some opioid drugs, such as heroin, morphine, or other prescription painkillers.
Reasons to use methadone are outlined below.
- Methadone is extremely effective. Individuals using methadone will not experience significant cravings to use other opioids and will not experience significant withdrawal symptoms.
- Methadone is cost-effective. The cost of using methadone maintenance as a MAT to recover from opioid dependence is relatively low compared to the use of other medications. In addition, research has indicated that the cost to society to leave an individual addicted to heroin or other opioid drugs is only slightly greater than the cost of incarcerating the individual. However, the cost of methadone maintenance treatment for one year is typically estimated at less than 10 times the cost of incarceration. Thus, methadone is cost-effective for the individual and for society.
- Methadone treatment is relatively safe for pregnant individuals. Although this finding remains somewhat controversial, methadone maintenance treatment is certainly far safer than using an opioid drug like heroin or even Vicodin when one is pregnant.
- Methadone maintenance programs are legal. The majority of individuals who abuse opioid drugs like heroin, morphine, Vicodin, OxyContin, etc., obtain them illegally. Being enrolled in a formal methadone maintenance program allows an individual to use a replacement medication legally under the supervision of a physician.
- Being in a methadone maintenance program allows individuals to consider their other options. When an individual is in a legal methadone maintenance program, they no longer have to be concerned with “getting their fix” and can begin to reflect on other changes that they might want to make with their life. While being caught up in the vicious cycle of drug abuse, a person is unable to do this.
- Methadone maintenance programs are safer than using drugs. Individuals in a formal methadone maintenance programs are at less risk to contract diseases associated with needle sharing, such as HIV or hepatitis, far less likely to die due to overdose, and far less likely to die from other complications, such as malnutrition.
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However, being in a methadone maintenance program is not a panacea. There are some drawbacks as well, outlined below.
- Many do not taper. One issue with many individuals in methadone maintenance programs, particularly for individuals who have opiate use disorders as a result of heroin abuse, is that these individuals are maintained on methadone for an ongoing period of time. Research has indicated that individuals who are on methadone maintenance for less than three months demonstrate little improvement, whereas the greatest improvements occur with individuals who remain in treatment for a year or longer.Because many of the aforementioned considerations outlined by the ASAM are not taken into account in the treatment of individuals in these programs, individuals who abruptly quit using methadone are at a high risk for relapse. In addition, because many individuals are maintained on methadone for lengthy periods of time, critics of methadone maintenance treatment programs state that society is simply replacing one addiction with another and not addressing the actual issue. While there is some truth to this critique, it is also true that long-term methadone maintenance treatment is effective for some individuals.
- Methadone maintenance also results in the development of physical dependence. Issues regarding relapse for individuals who abandon their methadone maintenance treatment include the potential to develop severe withdrawal symptoms and relapse. These individuals may go back to using a stronger drug that they once used (e.g., heroin), and the risk for overdose is also increased.
- Methadone maintenance appears to be ineffective in the treatment of polysubstance abuse and in criminal activities. A number of studies have indicated that while methadone maintenance treatment does address individuals with opiate use disorders, other issues, such as engaging in criminal activity (not associated with drug abuse) and even the use of other drugs like cocaine, are less likely to resolve as a result of this type of treatment.
It is hoped that getting the drug legally will reduce the risk of harm (e.g., the risk of hepatitis or HIV due to needle sharing) and decrease the potential of addicted individuals engaging in criminal activities, but this is not always the case. Methadone maintenance is generally considered less harmful and less sedating than other opioid use, and safe for even pregnant women. Therefore even if individuals abuse methadone, it is believed to be advantageous over the abuse of powerful illicit drugs like heroin or prescription drugs like OxyContin.
However, as mentioned above, methadone does carry risk for physical dependence and abuse. Many critics point out that one addiction is simply being replaced with another in methadone maintenance programs. Thus, these programs, according to these critics, are not successful in helping people recover from addiction, and they are inconsistent with the goals and specifications outlined by ASAM and APA for the use of MAT.
There are a few alternatives to methadone that one might consider. These include:
- Suboxone: Suboxone is a drug that contains two different medications: buprenorphine and naloxone. Buprenorphine is a drug that works similarly to methadone as an opioid replacement drug. The naloxone component is designed to safeguard against abuse of Suboxone. Naloxone remains ineffective unless an individual attempts to grind up the drug and snort or inject it. Naloxone is an opioid antagonist drug, and it is used when individuals overdose on opioid drugs. It immediately occupies all the neurons in the brain that opioid drugs attached to and reverses the effects of the opioids, including triggering a withdrawal syndrome.Suboxone has significant research to indicate its effectiveness as an opioid replacement medication, and it is typically administered on a tapering schedule. Individuals who become involved in MAT that includes the use of Suboxone typically are tapered off the drug and required to be involved in some formal substance use disorder treatment program as well.
- Clonidine: Clonidine is an antihypertensive drug that has found use in the treatment of the withdrawal syndrome from opioid drugs. Many individuals swear by its use, and this may be a drug that some individuals may want to consider. It does not appear to reduce cravings.
- Naltrexone: Naltrexone is a drug that has been used as a MAT for addressing cravings for a number of drugs, including opioids, alcohol, and others. It can be used in conjunction with drugs like clonidine in order to control cravings during the withdrawal process.
Anyone attempting to negotiate the withdrawal process from opioid drugs should consult with a physician. Even though the withdrawal process associated with an opioid use disorder is not generally considered to be potentially dangerous, individuals may actually be at risk for harm due to dehydration, lapses in judgment due to experiencing severe withdrawal symptoms such as vomiting and nausea, and potential accidents or self-harm associated with anxiety and/or depression.
All of the medications mentioned in this article should only be administered under the supervision of a physician. Attempting to use these medications without being under the care of a physician is extremely dangerous. Physicians can immediately address any issues associated with use of the medications, such as the development of allergic reaction. They can adjust the dosage to fit the particular case and use other MATs to control any complications that occur during the withdrawal process that are not addressed by these drugs.
Finally, an individual wishing to recover from a substance use disorder should become enrolled in a formal substance use disorder treatment program that includes MAT (if necessary), substance use disorder therapy, participation in support groups, social support from family and friends, and other interventions that are appropriate for the individual case. Simply trying to negotiate the withdrawal process without addressing the reasons that drove the substance abuse, or developing new skills to cope with stress and avoid relapse, is doomed to fail.