Download Methadone Maintenance Treatment (MMT)

A D D I C T I O N T R E AT M E N T
A Community-Centered Solution
for Opioid Addiction
Methadone Maintenance
Treatment (MMT)
Stewart B. Leavitt, PhD, Editor, Addiction Treatment Forum
Addiction to heroin and other opioids poses
serious problems for communities, families, and
individuals. Solutions sometimes seem uncertain,
difficult, and controversial.
During more than 40 years since its development, methadone maintenance treatment (MMT)
has helped millions of persons in recovery from
opioid addiction; allowing them to improve their
health, redeem their family and social lives, hold
down steady jobs or return to school, and generally
become productive tax-paying citizens in their
communities. Yet, the merits and effectiveness of
addiction treatment in general and MMT in
particular have not been universally understood
and accepted.
This booklet focuses on the evidence-based conclusions and educated commentary of credible
sources to provide a current and balanced perspective on the treatment of opioid addiction with
methadone.
Facts & Consequences of Opioid Addiction in America
Understanding Addiction As A Brain Disease
At one time, drug addiction was viewed as a failure of willpower or a flaw
of moral character. It was not recognized as a disease of the brain, in the same
way that mental illnesses previously were not viewed as such. Medical authorities have now accepted drug addiction as a chronic, relapsing disorder that
alters normal brain function, just as any other neurological or psychiatric illness.
Its development and expression are influenced by genetic, biological, psychosocial, and environmental factors. Outwardly, drug addiction is often characterized
by impaired control over continued drug use, compulsive use despite harmful
consequences, and/or intolerable drug craving.1,2
Addiction to opioid drugs is particularly insidious because the brain produces
its own opioid substances (e.g., endorphins) that are vital for survival. In effect,
the brain is “tricked” by external, short-acting opioid agents into responding as
if they are biologically essential. Once addiction sets in, brain chemistry becomes
unbalanced, and the person becomes physically, emotionally, and mentally
dysfunctional unless more opioid drug is regularly taken. Chronic opioid abuse
causes physiologic derangements lasting months or years after the last drugtaking episode. So, even if opioid-abstinence is eventually achieved, relapses
are common without ongoing therapy of some sort.1,2
Addiction tragically
“tricks” the brain into
thinking opioid drugs
are needed for
survival.
2
Medication-free
therapies alone
cannot stabilize
the chemical
upsets of opioid
addiction.
Many public officials and healthcare providers have expressed a strong bias
favoring “drug-free” treatment and eschewing the use of any medications
during recovery.3 However, such therapies for opioid addiction alone cannot
stabilize the chemical upsets associated with addiction and return brain
function to a more normal state.
The common stereotype depicts opioid-addicted persons as social misfits
and outcasts; however, such addiction is common throughout all segments of
society and in every community.4 Widely available and affordable access to
effective, community-based clinics providing methadone maintenance for the
disorder provides a viable solution for helping to stem America’s opioid-drug
addiction crisis.
Heroin Continues To Take A Toll
In the most recent reports, nearly 4 million Americans were classified as
dependent on or abusing illicit substances, and heroin addiction has continued
as a major concern.5 Heroin is derived from opium — as are morphine and
codeine — a product of the poppy plant and classified as an opiate narcotic.
A broader term, “opioid,” encompasses opium by-products and the many
synthetic drugs (such as, oxycodone, hydrocodone, propoxyphene, and others
including methadone) with properties similar to opium.6,7
The White House’s Office of National Drug Control Policy (ONDCP) has
estimated that there are more than 800,000 untreated chronic heroin users in
the United States, although this number is probably undercounted.3 Data on admissions to substance abuse treatment programs indicate that heroin dependence
has surpassed cocaine in some cases to become the most common diagnosis
behind alcoholism. Of interest, admissions for heroin use via inhalation have
been increasing due to its higher purity.5,8
High-purity, low-price,
heroin appeals to
youth, resulting in
addiction, the spread
of serious diseases,
and fatal drug
overdoses.
Reports from drug enforcement agencies indicate that during the past 2
decades heroin has become 30 times less expensive while its purity has increased more than 10-fold. A heroin “fix” can be purchased for as little as $5 and its
purity exceeds 70% in some major cities.9-11 Availability of low-cost, high-purity
heroin has fostered increased use, since it can be smoked, snorted, or otherwise
inhaled without the need for injection needles. This has attracted many new
users among youth, white, and middle class populations.5,9,11,12 Their experimentation eventually leads to injection and more severe addiction, and miscalculations of drug purity have led to fatal overdoses.3,13
The impact on public health has been severe. A typical intravenous-heroin
abuser may inject 4 or more times each day and this has been associated with
many serious communicable diseases, including: HIV/AIDS, hepatitis B and C,
and tuberculosis. More than a third of all adult and adolescent AIDS cases
reported in the U.S. have been associated with injection drug use.12,14 The prevalence of hepatitis C among intravenous-drug users ranges up to 90%,7,15 and
two-thirds may be infected with hepatitis B.14 Drug abusers are from 2 to 6 times
more likely to contract tuberculosis than nonusers,14 and almost half of the
patients in some opioid addiction treatment programs have positive tuberculin
skin tests.7 Finally, during the 1990s, heroin-related emergency department
visits more than doubled and the annual death toll increased by 74%.3,16
A D D I C T I O N T R E AT M E N T
3
Opioid Analgesics Are A Major Concern
One of the most troubling and increasing problems facing American communities is the abuse of opioid analgesic medications (painkillers), which has been
associated with addiction, drug overdoses, and deaths. The prevalence of
prescription-opioid abuse has surpassed illicit drug abuse.13,17 For example, in
2002 an estimated 4.4 million persons took pain relievers for non-medical
purposes, compared with 3.9 million persons who abused an illicit
substance, such as heroin, cocaine, etc.5
Oxycodone
Because methadone has become more widely prescribed as a potent
and cost-effective analgesic, it has been misused along with other opioids like oxycodone, hydrocodone, and morphine.17 Consequently,
throughout the past decade, there have been sharp increases in hospital
emergency department visits associated with opioid analgesics (see
graph),18 and also an upsurge in widely publicized overdose deaths
attributed to these drugs.13,17
352%
Unspecified
Opioid
288%
Methadone
230%
Morphine
Hydrocodone
As with any other opioid drug, methadone can be dangerous and
life-threatening if improperly used, and there have been long-standing concerns about the diversion of methadone for illicit purposes.16 However, in 1995,
a distinguished committee assembled by the Institute of Medicine concluded
that, “the actual level of abuse and harm from illicit methadone falls short of
its hypothetical potential for abuse… and is small relative to heroin and
cocaine.”19
Still, there were increasing reports of methadone-associated deaths in some
communities during 2001 to 2003. MMT clinics were blamed as the source of
diverted drugs and methadone was stigmatized as a “killer drug that should be
curtailed.” In response, an expert panel convened by the government’s
Substance Abuse and Mental Health Services Administration (SAMHSA)
unanimously concluded that opioid analgesics in general, most often
combined with other drugs or alcohol, were the major source of the
problems. Methadone itself was documented as the sole and direct
cause of death in relatively few cases, and the greatest source of the
drug came from its prescription by physicians as a painkiller; not from
MMT clinics.13
In fact, MMT programs provide a valuable service to their communities by treating residents who, for one reason or another, become
addicted to opioid painkillers. In one study, more than 80% of patients
admitted to MMT programs had been using prescription opioid medications at higher than therapeutic dosages, with or without heroin (see
pie graph).20 Nearly half had started their addiction by first misusing
analgesics and 24% were being treated solely for opioid-analgesic
dependency.
The majority of patients initiated opioid use due to ongoing pain problems,
rather than recreational use.20 However, experts have cautioned that fears of
producing dependency on opioid medications should not deter their appropriate prescription for patients in pain who would benefit from them. Pain is
seriously undertreated in the U.S. and reducing the availability of opioid
analgesics would exacerbate that problem.17
210%
131%
Increases in emergency
department visits.
4
How Methadone Maintenance Treatment (MMT) Works
Beneficial Effects Of Methadone For Opioid Addiction
Methadone was developed by German scientists in the late 1930s. It was
approved by the U.S. Food and Drug Administration (FDA) in 1947 as a
painkiller, and by 1950 oral methadone also was used to treat the painful
symptoms of persons withdrawing from opioids, usually heroin.19,21,22
MMT Benefits
An adequate maintenance
dose of methadone does
not make the patient feel
“high” or drowsy, so the
patient can generally carry
on a normal life. Daily
drug-seeking to “feed a
habit” ceases.
Methadone can be taken
once daily by mouth
without the use of injection
needles, which limits
exposure to diseases like
hepatitis and HIV.
Methadone’s gradual, longlasting effects eliminate
drug hunger or craving.
There is little change in
tolerance to methadone
over time, so it does not
take more of the drug to
achieve the same results.
Euphoria-blocking effects
of methadone make taking
illicit opioids undesirable.
Used properly, methadone
is generally safe and
nontoxic, with minimal
side effects.
In 1964, researchers at Rockefeller University, New York – headed by Vincent
Dole and Marie Nyswander – believed that opioid addiction was a “metabolic
disease” that altered brain function and made it difficult for patients to remain
drug-free.10,23 Dole’s team discovered that an ongoing, daily dose of long-acting
oral methadone –– maintenance treatment –– offered a number of beneficial
effects allowing otherwise debilitated opioid addicts to function more normally
(see box).15,16,23-27
MMT was viewed as corrective therapy, rather than as a “cure” for opioid
addiction, and it had no or only limited efficacy in treating dependence on
other substances of abuse.22 Dole wrote, “the most that can be said is that
there seems to be a specific neurobiological basis for the compulsive use of
heroin by addicts and that methadone taken in optimal doses can correct the
disorder.”23
Oral methadone has demonstrated a favorable safety profile when properly
prescribed and used. No serious adverse reactions or organ damage have been
specifically associated with continued methadone use extending more than 20
years in some patients. Minor side effects, such as constipation or excess sweating, may appear during early days of treatment and are easily managed.
Women stabilized on methadone generally have more healthful pregnancies
and their newborns do not suffer any lasting adverse consequences.15,26 Furthermore, methadone at appropriate dose levels does not hinder a patient’s intellectual capacities or abilities to perform work tasks.28
Adequate methadone dosing is critical for therapeutic success. Dole’s
original research discovered that 80 to 120 milligrams of methadone per day,
on average, was an effective dose. Dozens of studies since then have demonstrated that dosing in that range results in superior treatment outcomes, such
as better retention of patients in treatment and less illicit drug use.9,26,27 For a
variety of reasons — such as, high tolerance to opioids, physical condition,
mental status, concurrent medications, or prior use of high-purity heroin —
many patients require much higher daily methadone doses for treatment
success; sometimes exceeding 200 mg/day or more.15,26,29 Patients maintained on
inadequately low doses are much more likely to use illicit opioids and respond
poorly to therapy.28
In 1997, an independent panel of experts convened by the National
Institutes of Health (NIH) to reach a consensus on effective treatments for
opioid addiction concluded that, “Of the various treatments available [for
opioid addiction], MMT, combined with attention to medical, psychiatric, and
socioeconomic issues, as well as drug counseling, has the highest probability of
being effective.”16
A D D I C T I O N T R E AT M E N T
5
Ongoing MMT Is Essential & Cost Effective,
But Capacity Is Insufficient
Persons leaving
MMT and not
pursuing further
treatment are
almost certain
to relapse, with
potentially fatal
consequences.
Time in treatment is a critical factor for 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 take home a number of doses, thus reducing their clinic visits.3,30
Appropriate psychosocial therapy and other support services are integral components of ongoing MMT.
The NIH Consensus Panel16 and others31 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.3,19, 30-32 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.33
Virtually all who abandon MMT and do not pursue further treatment
eventually relapse34 and potentially overdose.13
MMT Growth
Unfortunately, MMT is not available for all who might benefit, even
though the number of patients in treatment has grown steadily and
incrementally through the years (see graph).9,35,36 In 2004, there were
about 1,100 MMT programs in 44 states; however, program capacity was
sufficient to serve only a small fraction of opioid-addicted persons in
this country who needed it; especially considering the additional numbers of persons addicted to opioid analgesics.3,15
205
220
179
# Patients
(000s)
117
73
82
95
0.4
1968
1973
1987
1991
1963
Methadone treatment is a cost effective alternative to incarceration
or hospitalization.3,24,30 Studies have shown that it costs about $42,000 per year
to leave a drug abuser untreated in the community, $40,000 if the offender is
incarcerated, and only about $3,500 for MMT.37 Furthermore, the National Institute
on Drug Abuse (NIDA) has reported that among MMT participants illegal activity
declined by 52% and full time employment increased by 24%.3 Patients in MMT
also earn more than twice as much money annually as opioid addicts not in treatment, which can enhance their value as taxpaying citizens in the community.16
An often-quoted study of 150,000 patients — the California Drug and Alcohol
Treatment Assessment (CALDATA) — found that for every $1 spent on addiction
treatment more than $7 in future costs were saved (see graph). MMT was
determined to be the lowest-cost, most effective treatment modality for opioid
addiction; whereas, programs offering only opioid detoxification showed no
long-term benefits at all.7
Deaths and illness associated with addiction are financially draining on society.
Untreated opioid addicts have a death rate 3 to 4 times greater than patients in
methadone treatment.13,16 Furthermore, studies have consistently shown that the
risk of communicable infections – HIV, hepatitis, tuberculosis – is significantly
reduced by MMT, even in the absence of complete illicit-drug abstinence.22,30,38 If
methadone clinics are closed communities pay a price. One study found that the
costs for crime, justice system (e.g., arrests), and welfare services in a community
that closed its MMT program were 17% higher when compared with a locality
with an ongoing MMT clinic.7
1999
2002
2004
$7
COST
SAVINGS
$1
Addiction treatment
provides a 700% return
on investment.
6
MMT Criticisms, Concerns, And Regulation
Past Practices And Misperceptions Have Hindered Progress
Through the years, MMT has fostered some negative attitudes and actions
by critics. A segment of public opinion has opposed the use of methadone for
treating opioid addiction and political initiatives have been enacted or proposed
to thwart access to MMT.39,40 Many persons still perceive opioid dependence as a
self-controllable “bad habit,” and dismiss MMT as an ineffective, addictivenarcotic substitution therapy.16,19
Methadone provides
a stable existence
that replaces high-risk,
self-destructive addictive
behaviors.
90
Average Dose (mg/day)
85
80
75
70
65
60
55
50
45
40
1988
1990
1993
1995
1998
However, it has widely and authoritatively been recognized that methadone
is not merely a substitute for illicit opioids, and MMT does not simply replace
one addiction with another.3,10,13,15,37,39,41 Although methadone can cause physical
dependence, its steady and long-term action in the brain contrasts sharply with
the disruptive cycle of “highs” and “lows” produced by short-acting opioids
that lead to addictive behaviors.9,15,24,42 Methadone substitutes a stable existence
for one of compulsive drug seeking and taking, criminal behavior, chronic
unemployment, and high-risk sexual and drug-use behaviors.3
Unfortunately, during the early days of MMT there were problems as a
result of rapid clinic expansion in the face of decreased funding.24,43 A government report found that clinic policies, goals, and practices varied widely,3,41
and departures from recommended methadone doses, adopting a
“less is more” approach, had pervaded many programs.9 Surveys since
1988 have observed that a majority of U.S. MMT clinics once provided
average methadone doses far below the 80 mg/day recommended
minimum.43 There have been improvements more recently, with most programs achieving average doses of 80 mg/day or more (see graph). However, many patients still receive inadequate amounts of methadone,43,44 and
they often respond poorly to treatment, just as would any individuals
2003
prescribed insufficient drug therapy for a chronic medical disorder.26,43
Regulations And Accreditation Promote “Best Practices”
Revised
regulations
allow for
more flexible
methadone
dosing and
take home
privileges.
MMT has been a tightly controlled medical specialty in the U.S. and
methadone itself is a highly regulated drug.9,16 Fairly recently, in 2001, oversight
of MMT programs was transferred to SAMHSA’s Center for Substance Abuse
Treatment (CSAT). Revised federal regulations emphasize improved patient care
and increased healthcare practitioner discretion in meeting patients’ needs;
particularly, allowing more liberal methadone dosing and permitting qualified
patients to take home doses for self-administration.30 However, state and local
regulations may be more stringent, and they are in some cases.
As a component of the regulations, MMT programs must successfully
complete an accreditation process similar to that required of much larger
healthcare organizations. Best-practice guidelines and standards have been
developed, reflecting the latest evidence promoting excellence in the
treatment of opioid addiction. Results to date indicate that MMT program
accreditation has been successful in improving patient care, safety, and
treatment outcomes.37
A D D I C T I O N T R E AT M E N T
7
Meeting Challenges for Change In Communities
Quality care for opioid-dependent persons also involves promoting their
reintegration, acceptance, and ongoing recovery from addiction in their
communities. Toward those ends, MMT staff seek to develop an understanding
of community values, needs, and resources; and, they strive to work collaboratively with community leaders and organizations at all levels.
Addiction treatment is sometimes viewed as a form of social welfare. However, from an MMT perspective, such treatment is a medical service that extends
beyond benefitting opioid-addicted patients. Public safety, health, and eventually the local economy often are the greater beneficiaries of methadone
maintenance treatment.3,37
Expanding Treatment
There is a provision in the revised federal regulations for office-based
physicians, who have formal arrangements with established MMT programs, to
provide methadone maintenance.30,45 This has been widely endorsed by government3,16,19,32 and medical33,46 organizations. It is estimated that at least 7% of patients
in MMT clinic programs are sufficiently stable to be served in this manner –
called methadone “medical maintenance” – and it would make additional MMT
clinic capacity available for opioid addicts awaiting treatment. However, this
approach has not been widely accepted and implemented.
In 2002, another opioid drug, buprenorphine, was approved by the government for prescription by qualified community-based physicians to treat opioid
addiction.26,47 However, it has been recognized that “buprenorphine is unlikely
to be as effective as more optimal-dose methadone, and therefore may not be
the treatment of choice for patients with higher levels of physical dependence
[on opioids].”37,47 Also, without the close monitoring, psychosocial therapy, and
other support provided by MMT clinics, the long-term benefits of buprenorphine
for some patients could be questionable.
Overcoming Stigma, Prejudice, And Misunderstandings
The World Health Organization and others have recognized that the stigma,
prejudice, and misunderstandings surrounding persons with addictive disorders
is a major barrier to their treatment and proper care.1,4 In particular, these negative pressures have served as obstacles to persons entering methadone treatment, to doctors in treating opioid addiction, and to legislators and public
health officials who could otherwise do more to make MMT widely available.
Past policies have placed too much emphasis on protecting society from
methadone and not enough on protecting communities from the epidemics of
addiction, violence, and infectious diseases that MMT can help reduce.19
Rather than embracing MMT as a solution, some short-sighted communities
have rallied against the opening of new MMT clinics – even in the midst of
ever-increasing opioid addiction problems – and forcing their citizens to travel
hours each day to other locales for methadone treatment. Hopefully, better,
evidence-based information and education will succeed in overcoming all of
the barriers facing MMT for the benefit of patients, their families, and their
communities.
Stigma, prejudice,
and misunderstandings
surrounding methadone
have served as
obstacles to persons
who would otherwise
enter treatment, to
doctors who might
do more in treating
opioid addiction,
and to legislators
and public health
officials who could
do more to make
MMT available.
8
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ADDICTION TREATMENT
is published by: Clinco Communications, Inc.
P.O. Box 685
Mundelein, IL 60060
© 2004 Stewart B. Leavitt, PhD
A.T. Forum is made possible by an educational grant from Mallinckrodt Inc.,
a manufacturer of methadone & naltrexone.
May 2004