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Methadone, a long-acting synthetic narcotic analgesic, was first used in the maintenance treatment of drug addiction in the mid-sixties by Drs. Vincent Dole and Marie Nyswander of Rockefeller University.  There are now 115,000 metha-done maintenance patients in the United States, 40,000 of whom are in New York State and about half that many are in California. Methadone is widely employed throughout the world, and is the most effective known treatment for heroin addiction.

The goal of methadone maintenance treatment is to reduce illegal heroin use and the crime, death, and disease associated with heroin addiction.  Methadone can be used to detoxify heroin addicts, but most heroin addicts who detox using methadone or any other method-return to heroin use. Therefore the goal of methadone maintenance treatment is to reduce and even eliminate heroin use among addicts by stabilizing them on methadone for as long as it is necessary to help them avoid returning to previous patterns of drug abuse.  The benefits of methadone maintenance have been established by hundreds of scientific studies, and there are almost no negative health consequences of long-term methadone treatment, even when it continues for twenty or thirty years.

The success of methadone in reducing crime,death,disease and drug use is well documented.   

*Methadone is the most effective treatment for heroin addiction.  Compared to the other major drug treatment modalities-drug-free outpatient treatment, therapeutic communities, and chemical dependency treatment-methadoneis the most rigorously studied  and has yielded the best results.

*Methadone is effective HIV/AIDS prevention.  Methadone maintenance treatment  reduces the frequency of injecting and needle sharing.  Methadone treatment is also an important point of contact with service providers and supplies an opportunity to teach drug users harm reduction techniques such as how to prevent HIV/AIDS, hepatitis, and other health problems that endanger drug users.

 *Methadone treatment reduces criminal behavior. Drug-offense arrests decline because methadone maintenance treatment patients reduce or stop buying and using illegal drugs.  Arrests for predatory crimes decline because methadone maintenance treatment patients no longer need to finance a costly heroin addiction, and because treatment allows many patients to stabilize their lives and obtain legitimate employment.      

 *Methadone drastically reduces, and often eliminates, heroin use among addicts.  The Treatment Outcome Prospective Study (TOPS)-the largest contemporary  controlled study of drug treatment-found that patients drastically reduced their heroin use while in treatment, with less than 10% using weekly or daily after just three months in treatment. After two or more years, heroin among methadone maintenance treatment patients declines, on average to 15% pretreatment levels.  Often the use of other drugs-including cocaine, sedatives, and alcohol-also declines when an opiate addict enters methadone treatment, even though methadone has no direct pharmacological effect on non-opiate use.  

*Methadone is cost effective.  Methadone Maintenance Treatment, which cost on the average about $4,000 per patient, per year, reduces the criminal behavior associated with illegal drug use, promotes health, and improves social productivity, all of which serves to reduce the societal costs of drug addiction.  Cost benefit analyses indicated savings of $4 to $5 dollars in health and social costs for every dollar spent on methadone maintenance treatment.  Incarceration costs $20,000 to $40,000 per year.  Residential Drug Treatment Programs are significantly more expensive than Methadone Maintenance Treatment, at a cost  of $13,000 to $20,000 per year, though it should be noted that treatment stays are typically no more than one year in these programs. Finally given that only only 5 to 10% of the cost of Methadone Maintenance Treatment actually pays for the medication itself, methadone could be prescribed and delivered even less expensively through physicains in general medical practice, service clinics, and pharmacies.    

*Methadone is effective outside of traditional clinic settings.  Methadone in the United States is generally restricted to specialized methadone clinics, which are subject to a host of counseling and other service requirements mandated by Federal, State, and Municipal Regulators. Though limited, experiments with providing methadone through alternate means have had positive results.  

*Limited Service Methadone Maintenance.  Limited Service Methadone Maintenance Treatment Services to addicts who cannot or will not access comprehensive methadone programs. Though limited service programs may not be as effective as the best full service programs, their patients do substanially reduce use and typically fare better than illicit drug users not enrolled in any program. 

*Physician Prescribing.  Methadone Maintenance Treatment as part of general medical practice is increasingly common throughout Europe, Australia, New Zealand and Canada, but it is severely restricted in the United States of America.  A few "Medical Maintenance Experiments" in the United States, which permitted some term methadone recipients to transfer from Traditional Clinics to Office-Based Physicians have achieved excellent treatment results.  Medical Maintenance is cost-effective, and patients often prefer it over Traditional Methadone Clinics.  

Questions About Methadone

If you feel you cannot stop using, before you inject again, think of all the liabilities that lie before you, disease, crime, loss of your husband and children, loss of your job, poverty and possibly death from overdosing. Give methadone a try???  

How does Methadone work?  Methadone is an opiate agonist which has a series of actions similiar to those of morphine and other narcotic medications. Heroin addicts are physically dependent on opiate drugs and will experience withdrawal symptoms and narcotic cravings if the concentration of opiates falls below a certain level.  The proper dose both wards off acute withdrawal symptoms and markedly reduces chronic narcotic cravings by stabilizing blood levels with the drug and its metabolites, thereby permitting "normal functioning".  In Methadone Maintenance Treatment, tolerance is deliberately induced to a stable dose  of methadone that is sufficiently high functioning  to block the narcotic and euphoria of methadone and other opiates.  

Does methadone make patients "high" and interfere with normal functioning?  No. Used in maintenance treatment, in proper doses, methadone does not create euphoria, sedation, or analgesia.  Methadone has no adverse effects on motor skills, mental capacity, or employability.

What is the proper dose of methadone?  Doses must be individually determined due to differences in metabolism, body weight, and opiate tolerance.  The proper mainte-nance dose is one at which narcotic craving is averted -without creating euphoria, sedation, or analgesia -for 24-36 hours  Doses of 60-100mg and some more, are required for most patients; doses below 60mg are almost always insufficent for patients who wish to abstain from heroin use.

Is methadone more addictive than heroin?  Physical dependence and tolerance of a drug are part of addiction, but they are not the whole story.  Addiction is characterized by compulsive use of a drug despite adverse consequences.  The methadone maintenance patient is no more an addict than the terminal cancer patient who is physically dependent on morphine, or the diabetic person who is dependent on insulin.  They do not seek out the drug in the absence of withdrawal symptoms and their lives do not revolve around drug use.   

Is methadone harder to kick than heroin?  Symptoms of abrupt withdrawal are qualitatively similiar when the amount of drug use is pharmacologically equivalent, withdrawal from heroin tends to be intense and fairly brief, while the methadone with-drawal is less acute and longer lasting.  Withdrawal symptoms can be ameliorated by tapering the dose over an extended period of time.

Is methadone treatment for life?  Some patients remain in methadone treatment for more than ten years, and even for the rest of their lives, but they constitute a minority (5 to  20%) of patients.

How long should treatment last?  Generally the lenght of time spent in treatment is postively related to treatment success.  The duration of treatment should be individually and clinically determined, and the treatment should last as long as the physician  and the individual patient agree is appropriate. Federal and often State Regulations require annual evaluation of patients to determine whether they should continue in Methadone Maintenance Treatment.  

Does methadone interfere with good health?  Scientific studies have shown that the most significant health consequence of long-term methadone maintenance is a marked improvement in general health. Concerns about methadone's effects on the immune system and on the kidneys , liver, and heart have been laid out to rest.  Methadone's most common side effects-constipation and sweating-usually fade  in time and are not serious health hazards.  

Is it safe to take methadone in pregnancy?  Methadone Maintenance Treatment during pregnancy does not impair the child's developemental  and cognitive functioning. Indeed it is the medically recommended course of treatment for opiate-dependent pregnant women.   

Is Methadone Maintenance appropriate for all drug users?  No.  Methadone is treatment for opiate dependence, and is not appropriate for individuals who use but are not, and have not been, dependent.  There are also drug-free treatment options and increasingly, other medications-including buprenorphine, LAAM, and naltrexone-that be appropriate for some users.  Outside the United States, some active drug users are being prescribed heroin, codeine, morphine and injectable morphine.  

Is methadone a desirable street drug, with high potential for drug abuse?  Though methadone is sometimes sold on the illicit drug market, most buyers of diverted methadone are active heroin users who won't or can't get into a methadone program. The extent of of abuse associated with diverted methadone is small relative to heroin, co-caine, and primary addiction to methadone is rare.  With improper use of methadone, like that of almost any drug, can lead to overdose, overdose deaths attributed to methadone alone are few compared to heroin deaths.  In its 1994 statement of emer-gency room incidents, the Drug Abuse Warning Network noted fifteen deaths,  two-hundred fifty-one morphine/heroin deaths and thirteen aspirin deaths. Finally all methadone deaths  are not neccessarily caused by illicitly purchased methadone, some are the results of accidental  or inappropriate consumption of legally obtained methadone; often in combination with alcohol or some other drugs. 

 TREATMENT OF OPIATE ADDICTION AS A METABOLIC DISEASE

In the nineteen sixties, researchers at The Rockefeller Universitybegan to question prevailing theories of addiction that were predicated on prevailing psychological attributes of addicted persons and conditioning theory. Dole and Nyswander (1970) indicated in an article addressing these ideas that heroin addiction may be a metabolical disease.  Clinical and laboratory studies suggest that the relapse- provoking narcotic hunger is symtomatic of a metabolic dysfunction within the endogenous opiate receptor-ligand system results from repeated use of opiates.

Although some patients function normally without medication after a period of treatment, the majority experience a return of drug hunger. If they do not reenter treatment, they are likely to relapse despite being motivated to remain abstinent and attempt to function normally within the community. Therefore, Methadone Maintenance is a corrective, not a curative procedure of indefinite duration (Dole 1970; Kreek 1973, 1976) 

Kreek studied subjects who detoxified from heroin or methadone and who succeeded in remaining abstinent from narcotics.  She observed during abstinence there was persistent abnormal neuroendocrine effects in both goups and has speculated these abnormal responses in neuroendocrine functioning can contribute to relapse (Kreek 1986 1988)/  With new analytic techniques available and the discovery of specific ligands that bind to receptors. Dole supports the renewed interest subject of protracted abstinence syndrome.

METHADONE AND DENTAL HEALTH



                           

The following notes from the Concord Hospital Dependency Seminar held in Australia summarize the issues and provide recommendations for dental health.

“Dental problems in addiction treatment subjects.  Does methadone rot teeth?  Can we prevent dental decay?

Main speaker:  Dr. Peter Foltyn (Dentist, St Vincent’s Hospital)

Dr. Halliman began by reminding us how much a smile is worth at a job interview as well as the draw backs of bad breath and poor nutrition which are so common in dependency cases.  He invited the large audience (of over 40) to benefit from Dr. Foltyn’s 20 year experience in treating such patients in his practice at Darlinghurst, Syndney. 

Dr. Foltyn gave us all a timely reminder of the importance of good dental care and the pitfalls of a number of factors countering dental hygiene.  He dealt with a number of important issues for patients with drug and alcohol problems including xerostomia (dry mouth).  When the salivary mechanism is inhibited there is a breakdown of the normal manner of diluting and removing debris resulting in a lower pH and an acidic environment of the teeth.  This allows penetration of the enamel especially at the gingival margins where it is thinnest and where it joins the dentine. 

Thus for patients who are taking antidepressants, anticholinergics and for some patients on methadone there is a need to counter dry mouth. The use of ‘swish and rinse’ at the time of medication (and at other times during the day and night) can be very effective in protecting the teeth.  Chewing gum can stimulate salivation and sugar-free gums are now available.  

Regular brushing after each meal, however, is still the mainstay of treatment  /prevention.  We were told that a medium brush with small, angled head is best and that much modern tooth paste is either is either unnecessary  and in some cases may cause irritation to already delicate buccal surfaces.  This, we were told, was largely due to the foaming agent used in virtually all proprietary brands available in supermarkets.  Sodium laurel sulfate has been shown to increase irritation is some people but they are currently only two brands available (largely at chemist shops) which omit the use of this chemical.  The other agents common to most tooth pastes an abrasive agent as well as a detergent.  It may be that brushing with just water is as effective as and less irritating to some people than using some pastes. We were told that while some electric tooth brushes have certain advantages, they are not necessary for optimal dental care. 

Another common cause of xerostomia in the hospital setting is head and neck radiotherapy.  It can be devastating for the teeth that occasionally extractions are recommended before radiation starts since healing is often so protracted afterwards.  Also, infections can set in, including one type of osteomyelitis which is almost untreatable. 

We were shown some shocking Technicolor anatomy-atlas-type-dental soft porn to demonstrate these matters.  Once getting over the initial shock of close- up dental views we then looked at projections of sequential x-rays of dentition in various states of dissolution (literally).  Some were in AIDS cases, others nutritional deficiencies, radiation stomatitis and cancer cases, including Kaposi’s sarcoma.  Plaque was discussed in length, as well as the various ways of dealing with it.  It was pointed out that in some cases plaque can extend under the gingival margins, requiring tooled removal by the dental surgeon.  Other exposed areas were dealt with and we were reminded about individual brushing, tooth by tooth on the three surfaces, lingua, buccal, and interfacial.  Gentle but purposive brushing to engage the gingival margin was stressed. Minor bleeding in inflamed areas is to be expected for a time but continued bleeding should always be examined by the dentist.  Flossing to clean the inter-dental surfaces should also be done regularly.  Three times yearly check-ups in patients at increased risk was also stressed. 

Topical fluoride should be applied in such high-risk individuals and the dental   fluoride ‘tray’ is the most effective way.  It is like a mouth guard which should be smeared with fluoride paste/gel and inserted for ten minutes before retiring.  Dr. Foltyn said that dentists will apply the same thing for a fee, but to do it oneself regularly is most appropriate for most of our patients. It would appear that fluoride can be effective even in late stage dental wear and tear. 

We were advised to tell our patients with poor dentition to avoid strong mouth washes with alcohol bases such as Listerine. A water-based mouth-wash with antiseptic is more appropriate and less likely to cause irritation. Chemists can advise on the types. 

The methadone “syrup” marketed in Australia still contains sorbitol which is sugar.  Although it is not actively absorbed and is safe for diabetics, as a sugar it is still a fuel for oral bacteria and alcohol with other constituents are not likely to help dental hygiene.  The sugar-free ‘solution’ Biodone should probably be our ‘first line’ product and the ‘syrup’ mainly used for those sensitive patients who are unable to tolerate the pure medicine.  But importantly, Dr. Foltyn says that this must not give any false sense of dental security as xerostomia will occur to the same degree with both products...

The use of buprenorphine may also cause dental problems although one would hope to a lesser degree than oral methadone syrup.  We need to watch carefully with this new medication and advise regular dental check-ups.

There are many other issues which had to be left to another session and there was lively discussion on this pressing issue.  We need to examine better analgesia during and after dental surgery in dependency patients.  Antibiotics in those with heart murmurs, prosthetic joints, etc. need to be addressed.  Putting more resources into high risk cases should be a public health priority as good teeth can improve self-confidence, job prospects and even romance.

Modified: July 2, 2005                    Deborah Shrira RPH,CMA

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