Methadone Maintenance Treatment    
   
 

 

VERSILIONE ITALIANAItalian Version

Methadone, a long-acting synthetic narcotic analgesic, was first used in the maintenance treatment of drug addiction in the mid-1960s, by Drs. Vincent Dole and Marie Nyswander of Rockefeller University. There are now 115,000 methadone maintenance patients in the U.S. 40,000 of them are in New York State, and about half that many are in California.(1) Methadone is widely employed throughout the world, and is the most effective known treatment for heroin addiction.(2)

The goal of methadone maintenance treatment (MMT) is to reduce illegal heroin use and the crime, death, disease, and other negative consequences associated with 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 is necessary to help them keep their lives together and avoid returning to previous patterns of drug use. The benefits of methadone maintenance treatment 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.(3)

  • 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 -- methadone is the most rigorously studied and has yielded the best results.(4)
  • Methadone is effective HIV/AIDS prevention.(5)
    MMT reduces the frequency of injecting and of needle sharing.(6) 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 -- including abscesses, dermatitis, and overdoses -- that endanger drug users.(7)
  • Methadone treatment reduces criminal behavior.(8)
    Drug offense arrests decline because MMT patients reduce or stop buying and using illegal drugs. Arrests for predatory crimes decline because MMT patients no longer need to finance a costly heroin addiction, and because treatment allows many patients to stabilize their lives and return to legitimate employment.
  • Methadone drastically reduces, and often eliminates, heroin use among addicts.(9)
    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 heroin weekly or daily after just three months in treatment.(10) After 2 years or more, heroin use among MMT patients declines, on average, to 15% of pre-treatment levels.(11) Often, use of other drugs -- including cocaine,(12) sedatives,(13) and even alcohol(14) -- also declines when an opiate addict enters methadone treatment, even though methadone has no direct pharmacological effect on non-opiate drug craving.
  • Methadone is cost effective.
    MMT, which costs on average about $4,000 per patient per year,(15) reduces the criminal behavior associated with illegal drug use, promotes health, and improves social productivity, all of which serve to reduce the societal costs of drug addiction.(16) Incarceration, by comparison, costs $20,000(17) to $40,000(18) per year. Residential drug treatment programs cost $13- 20,000/year.(19) Furthermore, given that only 5-10 percent of the cost of MMT actually pays for the medication itself,(20) methadone could be prescribed and delivered even less expensively, through physicians in general medical practice, low-service clinics, and pharmacies.

Methadone is Effective Outside of Traditional Clinic Settings: Methadone in the U.S. 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 MMT is a low-cost method of providing methadone 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 substantially reduce drug use and typically fare better than do illicit drug users not enrolled in any programs.(21)
  • Physician Prescribing
    MMT as part of general medical practice is common throughout Europe, Australia, and New Zealand, but is severely restricted in the U.S. There have been U.S. “medical maintenance” trials, which permitted some long-term methadone recipients to transfer from traditional methadone clinics to hospital- based physicians. Medical maintenance, where tested, has achieved excellent treatment results.(22) Medical maintenance is also cost effective, and patients prefer it over traditional methadone clinics.(23)

Questions About Methadone

  • How does methadone work?
    Methadone is an opiate agonist which has a series of actions similar to those of morphine and other narcotic medications.(24) Heroin addicts are physically dependent on opiate drugs, and will experience withdrawal symptoms if the concentration of opiates in the body falls below a certain level. In maintenance treatment, patients are given enough methadone to ward off opiate withdrawal symptoms, but not enough to induce narcotic effects.(25)
  • Does methadone make patients “high” or interfere with normal functioning?
    No. Used in maintenance treatment, in proper doses, methadone does not create euphoria, sedation, or analgesia.(26) Methadone has no adverse effects on motor skills, mental capability, or employability.(27)
  • What is the proper dose of methadone?
    Dose must be individually determined, because of differences in metabolism, body weight, and opiate tolerance.(28) The proper maintenance dose is one at which narcotic craving is averted -- without creating euphoria, sedation, or analgesia -- for 24-36 hours.(29) Doses of 60-100 mg, and sometimes more, are required for most patients,(30) and doses below 60 mg are almost always insufficient for patients who wish to abstain from heroin use.(31)
  • Is methadone more addictive than heroin?
    Physical dependence and tolerance to a drug are part of addiction, but they’re not the whole story. Addiction is characterized by compulsive use of the drug despite adverse consequences.(32) The MMT patient is no more an addict than the terminal cancer patient who is physically dependent on morphine, or the diabetic who is dependent on insulin. They do not seek out the drug in the absence of withdrawal symptoms or pain, and their lives do not revolve around drug use.
  • Is methadone harder to kick than heroin?
    Symptoms of abrupt withdrawal are qualitatively similar when the amount of drug used is pharmacologically equivalent, but withdrawal from heroin tends to be intense and fairly brief, while methadone withdrawal is less acute and longer lasting.(33) Withdrawal symptoms can be ameliorated by tapering the dose over an extended period of time.(34)
  • Is methadone maintenance 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 (5-20%) of patients.(35)
  • How long should treatment last?
    Generally, the length of time spent in treatment is positively related to treatment success.(36) The duration of treatment should be individually and clinically determined, and treatment should last for as long as the physician and the individual patient agree is appropriate.(37) Federal, and often state, regulations require annual evaluation of patients to determine whether they should continue in MMT.(38)
  • Is methadone a desirable street drug, with high potential for 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.(39) The extent of abuse associated with diverted methadone is small relative to heroin and cocaine, and primary addiction to methadone is rare.(40) While methadone, like almost any drug, can cause overdoses if used improperly, overdose deaths attributed to methadone alone are few, and are incidental compared to heroin deaths. The Drug Abuse Warning Network found, in its 1994 sample of emergency room incidents, 15 methadone deaths, 251 heroin/morphine deaths, and 13 aspirin deaths.(41) Finally, not all methadone overdose deaths are necessarily caused by illicitly purchased methadone; some are undoubtedly the result of accidental or inappropriate consumption of legally obtained methadone.
  • Does methadone interfere with good health?
    Scientific studies have shown that the most significant health consequence of long term methadone treatment is a marked improvement in general health.(42) Concerns about methadone’s effects on the immune system(43) and on the kidneys, liver, and heart(44) have been laid to rest. Methadone’s most common side effects -- constipation and sweating -- usually fade with time, and are not serious health hazards.(45)
  • Is it safe to take methadone during pregnancy?
    MMT during pregnancy does not impair the child’s developmental and cognitive functioning, and it is the medically recommended course of treatment for most pregnant opiate-dependent women.(46)
  • Is methadone maintenance appropriate for all drug users?
    No. Methadone is a treatment for opiate dependence, and is not appropriate for individuals who use heroin but are not, and have not been, dependent.(47) There are also drug-free treatment options and, increasingly, other medications - - including buprenorphine and LAAM -- that may be appropriate for some users.(48)

For further information on this topic contact Jennifer McNeely. For media requests, contact Sharon Herbstman.

Endnotes

  1. Institute of Medicine, Federal Regulation of Methadone Treatment (Washington, DC: National Academy Press, 1995), 170, 174.
  2. Institute of Medicine, Treating Drug Problems, vol. 1 (Washington, DC: National Academy Press, 1990), 187.
  3. See, e.g., Institute of Medicine, Federal Regulation of Methadone Treatment (Washington, DC: National Academy Press, 1995); Institute of Medicine, Treating Drug Problems, vol. 1, op. cit.; J.C. Ball and A. Ross, The Effectiveness of Methadone Maintenance Treatment (New York: Springer-Verlag, 1991); V.P. Dole, M. Nyswander, and A. Warner, “Successful treatment of 750 criminal addicts.” Journal of the American Medical Association, 206, 1968, 2708-2711; M.D. Anglin and W.H. McGLothlin, “Outcome of narcotic addict treatment in California.” In F.M. Tims and J.P. Ludford (Eds), Drug Abuse Treatment Evaluation: Strategies, Progress, and Prospects, NIDA Research Monograph 51 (Maryland: National Institute on Drug Abuse, 1984); R.L. Hubbard et al., “Treatment Outcome Prospective Study (TOPS): Client characteristics and behaviors before, during, and after treatment.” In F.M. Timms and J.P. Ludford (Eds), Drug Abuse Treatment Evaluation: Strategies, Progress, and Prospects, op. cit. ; Also see the primary randomised controlled studies of methadone’s effectiveness: V.P. Dole et al., “Methadone treatment of randomly selected criminal addicts.” New England Journal of Medicine, 280, 1969; R.G. Newman and W.B. Whitehill, “Double-blind comparison of methadone and placebo maintenance treatments of narcotic addicts in Hong Kong.” Lancet, Sept. 8, 1969; and L. Gunne and L. Grönbladh, “The Swedish methadone maintenance program: A controlled study.” Drug and Alcohol Dependence, 24, 1981.
  4. See Institute of Medicine, Treating Drug Problems, vol. 1, op.cit., p., 187; The TOPS study of over 11,000 drug users found that retention in treatment is the best predictor of treatment success, and found that methadone had the best retention rates of all three treatment modalities studied (methadone maintenance, therapeutic communities, and drug-free outpatient treatment). R.L. Hubbard et al., “Treatment Outcome Prospective Study (TOPS),” op. cit.; R. L. Hubbard et al., Drug Abuse Treatment: A National Study of Effectiveness (University of North Carolina Press, 1989); also see discussion in J. Ward, R. Mattick, W. Hall, Key Issues in Methadone Maintenance Treatment (New South Wales, Australia: New South Wales University Press, 1992), 29-32.
  5. D.M. Novick et al., “Absence of Antibody to Human Immunodeficiency Virus in Long-term, Socially Rehabilitated Methadone Maintenance Patients.” Archives of Internal Medicine, vol. 150, January, 1990; A.S. Abdul-Quadar et al., “Methadone maintenance and behavior by intravenous drug users that can transmit HIV.” Contemporary Drug Problems, 14, 1987, 425-434; A. Chu et al., “Intravenous heroin use: Its association with HIV infection in patients in methadone treatment.” In L.S. Harris, Ed., Problems of Drug Dependence 1989, NIDA Research Monograph, 95, 447-448; R.E. Chaisson et al., “Cocaine use and HIV infection in intravenous drug users in San Francisco.” Journal of the American Medical Association, 261, 1989, 561-65.
  6. J.C. Ball and A. Ross, op. cit., 166-170; J.C. Ball et al., “Reducing the risk of AIDS through methadone maintenance treatment.” Journal of Health and Social Behavior, 28, 1988, 214-226. See also P.A. Selwyn et al., “Knowlege about AIDS and high-risk behavior among intravenous drug users in New York City.” AIDS, 1, 1987, 1289-94; S. Darke et al., “The reliability and validity of a scale to measure HIV risk taking behavior among intravenous drug users.” AIDS, 5, 1991, 181-85; both discussed in J. Ward, R. Mattick, W. Hall, op. cit., 56.
  7. J. Ward, R. Mattick, W. Hall, op. cit., 46-61.
  8. R.L. Hubbard et al., “Treatment Outcome Prospective Study (TOPS),” op. cit.; J.C. Ball and A. Ross, op. cit., 195-211; H. Joseph, “The Criminal Justice System and Opiate Addiction: A Historical Perspective.” In C.G. Leukefeld and F.M. Tims (Eds), Compulsory Treatment of Drug Abuse: Research and Clinical Practice, NIDA Research Monograph 86 (Rockville, Maryland: National Institute on Drug Abuse, 1988), 117; R. G. Newman and N. Peyser, “Methadone treatment: Experiment and experience.” Journal of Psychoactive Drugs, 23, no. 2, 1991, 115-21.
  9. R.L. Hubbard et al., “Treatment Outcome Prospective Study (TOPS),” op. cit.; J.C. Ball and A. Ross, op. cit., 160-176; Institute of Medicine, Treating Drug Problems, vol. 1,op. cit., 136-153; Institute of Medicine, Federal Regulation of Methadone Treatment, op. cit., 22; R.G. Newman, Methadone Treatment in Narcotic Addiction (New York: Academic Press, 1977).
  10. R.L. Hubbard et al., “Treatment Outcome Prospective Study (TOPS),” op. cit.
  11. Institute of Medicine, Federal Regulation of Methadone Treatment, op. cit., 22.
  12. S. Magura, Q. Siddiqi, R.C. Freeman, and D.S. Lipton, "Changes in Cocaine Use After Entry to Methadone Treatment," in Cocaine, AIDS, and Intravenous Drug Use (New York: Haworth Press, 1991); J.C. Ball and A. Ross, op. cit., 160- 175; D. Hartel et al., “Temporal patterns of cocaine use and AIDS in intravenous drug users in methadone maintenance [Abstract]. 5th International Conference on AIDS, Montreal, Canada, June, 1989, cited in J.H. Lowinson et al., “Methadone Maintenance.” in J.H. Lowinson, P. Ruiz, R.B. Millman (Eds.), Substance Abuse: A Comprehensive Textbook, 2nd Ed. (Baltimore, Maryland: Williams & Wilkins, 1992), 550-61.
  13. A. Fairbank, G.H. Dunteman, W.S. Condelli, “Do methadone patients substitute other drugs for heroin? Predicting substance use at 1-year follow-up.” American Journal of Drug and Alcohol Abuse, 19, 1993, 465-74, discussed in G. Bertschy, “Methadone maintenance treatment: an update.” Eur Arch Psychiatry Clin Neurosci, 245, 1995, 114-24; J.C. Ball and A. Ross, The Effectiveness of Methadone Maintenance Treatment, op. cit., 160-175.
  14. Ibid.
  15. Institute of Medicine, Treating Drug Problems, vol. 1, op. cit., 151-52; N. Swan, “Research Demonstrates Long-Term Benefits of Methadone Treatment.” NIDA Notes, 9, no. 4, 1994.
  16. H.J. Harwood et al., “The costs of crime and the benefits of drug abuse treatment: a cost benefit analysis using TOPS data.” In C.G. Leukefeld and F.M. Tims (Eds), Compulsory Treatment of Drug Abuse: Research and Clinical Practice, NIDA Research Monograph 86 (Rockville, Maryland: National Institute on Drug Abuse, 1988), 209-135.; N. Swan, op. cit.; Institute of Medicine, Treating Drug Problems, vol. 1, op. cit., 151-52.
  17. Criminal Justice Institute, The Corrections Yearbook: Instant Answers to Key Questions in Corrections (New York: Criminal Justice Institute, 1995).
  18. G. Godshaw, R. Koppel, R. Pancoast, “Anti-Drug Law Enforcement Efforts and Their Impact” (Washington, D.C.: U.S. Customs Services, Dept. of the Treasury, August, 1989), cited in N. Swan, op. cit.
  19. Institute of Medicine, Treating Drug Problems, vol. 1, op. cit., 189.
  20. Institute of Medicine, Federal Regulation of Methadone Treatment, op. cit., 162.
  21. S. R. Yancovitz, et. al., "A Randomized Trial of an Interim Methadone Maintenance Clinic." American Journal of Public Health, 81, no. 9, Sept., 1991, 1185-91; R. G. Newman, ,"Narcotic Addiction and Methadone Treatment in Hong Kong." Journal of Public Health Policy, 6, no. 4, Dec. 1985, 526-38; E.C. Buning et al., “Preventing AIDS in drug addicts in Amsterdam.” Lancet I, 1986. Also see A. T. McClellan, I. O. Arndt, D. Metzger, G. Woody, and C. P. O'Brien, "The Effects of Psychosocial Services in Substance Abuse Treatment," Journal of the American Medical Assoc. 269, 1993, 1953-59. Though this study concluded that minimal service methadone treatment was ineffective, patients who received minimal services did substantially reduce their heroin use.
  22. D. M. Novick, E. F. Pascarelli, H. Joseph et al., “Methadone Maintenance Patients in General Medical Practice.” Journal of the American Medical Assoc., 259, 1988, 3299-3302; D.M. Novick et al., “Medical Maintenance: A New Model for Continuing Treatment of Socially Rehabilitated Methadone Maintenance Patients.” Journal of the American Medical Assoc., 259; 3299-3302, 1988; D.M. Novick et al., “Outcomes of Treatment of Socially Rehabilitated Methadone Maintenance Patients in Physicians’ Offices (Medical Maintenance).” Journal of General Internal Medicine (Hanley & Belfus, Inc.: Philadelphia, PA, 1994), 127- 130; D. M. Novick and H. Joseph, “Medical Maintenance: The Treatment of Chronic Opiate Dependence in General Medical Practice.” Journal of Substance Abuse Treatment, 8, 1991, 233-239; E.C. Senay et. al., “Medical Maintenance: An Interim Report.” Journal of Addictive Diseases, 13, no. 3, 1994, 65-69.
  23. Ibid.
  24. R.G. Newman, “The Pharmacological Rationale for Methadone Treatment of Narcotic Addiction.” In A. Tagliamonte and I. Maremmani (Eds.), Drug Addiction and Related Clinical Problems (New York: Springer-Verlag Wien, 1995), 109-18.
  25. Ibid.; E. Drucker, “Harm Reduction: a public health strategy.” Current Issues in Public Health 1, 1995, 64-70.
  26. J.H. Lowinson et al., “Methadone Maintenance,” op. cit., 552.
  27. Regarding Methadone Treatment: A Review (New York: New York State Committee of Methadone Program Administrators, Inc., 1995), 7; J.H. Lowinson et al., “Methadone Maintenance,” op. cit., 553-54; R.G. Newman, “The Pharmacological Rationale for Methadone Treatment of Narcotic Addiction,” op. cit.
  28. J.H. Lowinson et al., “Methadone Maintenance,” op. cit., 552-53; J. Ward, R. Mattick, W. Hall, Key Issues in Methadone Maintenance Treatment, op. cit., 86- 115;
  29. J.H. Lowinson et al., “Methadone Maintenance,” op. cit., 552-53; J.T. Payte and E.T. Khuri, “Principles of Methadone Dose Detrmination.” In State Methadone Treatment Guidelines, op. cit., 47-58.
  30. State Methadone Treatment Guidelines, op. cit., 18-19; Institute of Medicine, Treating Drug Problems, op. cit., 149-50; J. Ward, R. Mattick, W. Hall, Key Issues in Methadone Maintenance Treatment, op. cit., 96-104.
  31. J.H. Lowinson et al., “Methadone Maintenance,” op. cit., 552-53; J.T. Payte and E.T. Khuri, “Principles of Methadone Dose Detrmination.” In State Methadone Treatment Guidelines, op. cit.; W.A. Hargreaves, “Methadone dosage and duration for maintenance treatment.” In J. R. Cooper et al. (Eds.), Research on the Treatment of Narcotic Addiction: State of the Art, op. cit.; J.R. Cooper, F. Altman, K. Keeley, Discussion Summary of W.A. Hargreaves, “Methadone dosage and duration for maintenance treatment,” op. cit.; J. Ward, R. Mattick, W. Hall, Key Issues in Methadone Maintenance Treatment, op. cit., 86-115; J.T. Payte and E.T. Khuri, “Principles of Methadone Dose Detrmination.” In State Methadone Treatment Guidelines, op. cit., 47-58; J.R.M. Caplehorn and J. Bell, “Methadone dosage and retention of patients in maintenance treatment.” The Medical Journal of Australia 154, 1991, 195-99.
  32. nstitute of Medicine, Federal Regulation of Methadone Treatment, op. cit., 210.
  33. E. Velten, “Myths About Methadone.” In National Alliance of Methadone Advocates Education Series, 3, 1992; J. Ward, R. Mattick, W. Hall, op. cit., 196- 215; A. Byrne, Methadone in the Treatment of Narcotic Addiction (Redfern, New South Wales, Australia: Tosca Press, 1995), 53-54.
  34. J. Ward, R. Mattick, W. Hall, op. cit., 196-215.
  35. G. Bertschy, “Methadone maintenance treatment: an update,” op. cit.
  36. D.D. Simpson, “The relation of time spent in drug abuse treatment to post- treatment outcome.” American Journal of Psychiatry, 136, 1979, 1449-53; D. D. Simpson, “Treatment for drug abuse: Follow-up outcomes and length of time spent.” Archives of General Psychiatry, 38, 1981, 875-80; and R.L. Hubbard et al., “Treatment Outcome Prospective Study (TOPS),” op. cit., all discussed in J. Ward, R. Mattick, W. Hall, op. cit.
  37. J.T. Payte, E.T. Khuri, “Treatment Duration and Patient Retention.” In State Methadone Treatment Guidelines, op. cit., 119.
  38. Regarding Methadone Treatment: A Review, op. cit., 15.
  39. State Methadone Treatment Guidelines, op. cit., 6; B. Spunt, D. Hunt, D. Lipton, D. Goldsmith, “Methadone Diversion: A New Look.” Journal of Drug Issues, Fall 1986, 569-583.
  40. Institute of Medicine, Federal Regulation of Methadone Treatment, op. cit., 114.
  41. These are all deaths which can be directly attributed to the named drug alone. Excluded are incidents involving multiple drugs, physiological condition, external physical events, and medical disorders that distort the actual cause of death. U.S. Dept. of Health and Human Services, Data from the Drug Abuse Warning Network (DAWN), Medical Examiner Data (Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, May 1995 data file), Table 2.10.
  42. M. J. Kreek, "Health consequences associated with the use of methadone." In J. R. Cooper et al. (Eds.), Research on the Treatment of Narcotic Addiction: State of the Art. NIDA Treatment Research Monograph Series. DHHS Pub. No. (ADM)83-1281 (Rockville, Md.: National Institute on Drug Abuse, 1983).
  43. M. J. Kreek, "A Personal Retrospective and Prospective Viewpoint." In State Methadone Treatment Guidelines, op. cit., 138.
  44. National Institute on Drug Abuse, Medical Evaluation of Long-Term Methadone-Maintained Clients, NIDA Services Research Monograph Series, DHHS Publication No. (ADM)81-1029 (NIDA: Rockville, MD, 1980).
  45. J.H. Lowinson et al., “Methadone Maintenance,” op. cit., 553.
  46. K. Kaltenbach, N. Silverman, R. Wapner, “Methadone Maintenance During Pregnancy.” In State Methadone Treatment Guidelines, op. cit., 85-93; L.P. Finnegan, “Treatment Issues for Opioid-Dependent Women During the Perinatal Period.” Journal of Psychoactive Drugs, 23, 1991, 191-201; L. P. Finnegan, “Clinical perinatal and development effects of methadone.” In J. R. Cooper et al. (Eds.), Research on the Treatment of Narcotic Addiction: State of the Art, op. cit.; Institute of Medicine, Federal Regulation of Methadone Treatment, op. cit., 203- 4; J. Ward, R. Mattick, W. Hall, Key Issues in Methadone Maintenance Treatment, op. cit., 235-56; M.A.E. Jarvis, S.H. Schnoll, “Methadone Treatment During Pregnancy.” Journal of Psychoactive Drugs, 26, 1994, 155-61.
  47. J. Ward, R. Mattick, W. Hall, Key Issues in Methadone Maintenance Treatment, op. cit., 65-85; Institute of Medicine, Treating Drug Problems, vol. 1, 136.
  48. See, e.g., Institute of Medicine, The Development of Medications for the Treatment of Opiate and Cocaine Addictions (Washington, DC: National Academy Press, 1995); and Buprenorphine: Combatting Drug Abuse with a Unique Opioid (New York: Wiley-Liss, 1995).

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