Methadone in the Treatment of Narcotic Addiction. Chapter 2

Rationale for Treatment

The principle behind the medical supply of methadone to addicts lies in the observation that the use of narcotic drugs can be consistent with a productive and wholesome life. There are many historical accounts of prominent citizens using narcotics. The abstinence philosophy held by some people should not deny others the right to choose maintenance treatment as a valid alternative. A substantial body of evidence now supports methadone treatment as effective, safe and acceptable (10,11).

Those outside the field sometimes ask whether addiction is a disease and if methadone is really a 'treatment'? Such interesting debate, however, is unproductive and unhelpful to the sufferer.

For any drug treatment to be indicated, the drug must have proven benefit, and non-drug treatments must be inappropriate. An effective dose should be prescribed with all due care and safeguards. In this field, inadequate doses can be as harmful as toxic ones.

Opiates are found in many guises; from poppy seeds used in the kitchen, through 'over-the-counter' pain killers, cough suppressants, diarrhoea remedies, prescribed analgesics and opium, to injected heroin. All these agents can cause the addiction syndrome. Although prescribed intravenous heroin has been used as a treatment with some promise, the intrinsic risks, higher cost, and the need for specialist supervision make it unsuitable in most situations.

It is now known that there are large numbers of citizens who use heroin on an infrequent basis. They are not addicted and only a small proportion ever seek medical treatment.

The majority of those attending for methadone treatment have had a long career of drug use, culminating in compulsive heroin use. Rather than open prescription, treatment should be in the context of a medical strategy aimed at the patient's long-term well being. Hence it is important that the physician be skilled in the use of methadone both to avoid its pitfalls, and in order to maximise its benefits for the patient.

The ban on doctors prescribing methadone which still pertains in some jurisdictions is curious indeed. To deny doctors and their patients a safe and effective drug for such a common and serious condition would be unheard of in any other discipline.

Why Methadone?

Any safe narcotic possessing cross-tolerance with heroin could theoretically be used as a replacement treatment for opioid addiction. Methadone, however, has pharmacokinetic and practical attributes making it the current drug of choice for this purpose.

The half-life of methadone is usually in excess of twenty four hours and can be as long as three days in some individuals. Its regular administration causes tolerance to develop in opioid receptors so that patients experience diminished effects from morphine or heroin. This lessens the attraction of using illicit opiates, and also reduces the risk of overdose. The oral absorption of methadone is almost 100%. Being synthesised, it is cheap to produce, an average dose costing less than one dollar.

Such has been its success that many patients request methadone by name. Some have taken the drug from the black market, while others have noted improvements in patients on treatment. No other narcotic can be prescribed to addicts with such a degree of safety.

In summary, methadone is an appropriate treatment for opioid addiction because of its:

• Long duration of action.
• Cross-tolerance with other opioids.
• Effective oral administration.
• Good research standing.
• Economy.

Research Basis for Current Practice

Methadone use in clinical practice has been refined according to research findings. Medical practice per se has evolved since the 1960s. Patients are now more involved in decision-making. The public is better informed about medical issues and patients are more aware of their rights as consumers. It is not appropriate for doctors and other health professionals to treat patients in a paternalistic manner using arbitrary measures which are not based on sound medical principles.

A review of the scientific literature on methadone treatment compiled in 1992 gives many conclusions applicable to clinical practice (12). Much of this research, however, dates from the 'pre-HIV' era and some outcomes were judged using the older, less sensitive urine screens. The conclusions are derived from a large number of studies concerning all aspects of the treatment domain. Dose levels, patient involvement in setting the levels, counselling, urine tests and associations with subsequent outcomes were examined. These consistently demonstrated that patients who are given limited doses for short periods on rigid programs had less favourable outcomes when compared with those given more liberal treatment protocols. These studies also confirm that 'deregulation' does not result in all patients taking high doses, nor do all patients remain on methadone indefinitely (13,14,15). While in treatment, patients are less likely to contract HIV/AIDS (16), and those remaining in treatment longer are more likely to remain drug-free after leaving treatment.

The most consistent research finding with methadone treatment is a reduction in the use of injected heroin. Decreases in the use of other drugs, including alcohol, are also commonly described, implying a factor beyond simple chemical replacement (17). Such a treatment factor, independent of the methadone doses or patient selection, was also described by Ball in his study of six methadone treatment services in three American cities (18). He called it the 'black box' effect and ascribed it to the combination of factors making up the treatment milieu. Other researchers have shown in patients on comparable methadone doses, improved outcomes with additional counselling and support (19). Some patients who were denied any ancillary services in a research study (the 'drug only group') had to be moved to the 'counselling' group for their own protection. These non-drug effects parallel observations in other branches of medicine where sympathetic understanding and support services also lead to improved results.

Methadone Myths

Stories about the supposed dangers of methadone are widespread. One source is heroin dealers who are threatened by their clients going into treatment. Some community leaders and commentators also rail against 'methadone' from conspicuous positions of ignorance.

Methadone is said to lead to dental decay and chalky bones, to be more addictive than heroin, to rot the bowels and prevent exercise training. Such mis-information can deter addicts from seeking appropriate treatment. Patients often state that if they had known of the benefits of methadone, they would have come into treatment earlier.

Withdrawals are a function of overall drug dependence in the individual, and not a function of the drug itself. There is no evidence that the availability of methadone delays eventual abstinence. The reverse may be the case.

The invention of the term 'Adolphine' by New York City street linguists in the 1970s was an apparent attempt to discredit methadone treatment by those unsympathetic to it, using the Hitler association.

There is also much ignorance about methadone in the wider community. Bad news travelling faster than good, people are often aware of methadone treatment because of the visible minority. Newspapers will carry stories of outraged residents confronted with needles, syringes, take-home bottles and other paraphernalia. Rarely seen are headlines about methadone treatment reducing these problems.

Some doctors also harbour misconceptions about methadone. Erroneous beliefs include the concept that few patients ever come off treatment successfully; that those on high doses have a more serious addiction problem; or that the treatment is not based on sound Hippocratic principles.

Some medical practitioners are suspicious of drug addicts due to past deceptions of some narcotic-seeking patients. This cycle of mistrust will only break down when the medical profession is able to treat addictions in the same way as it treats other chronic relapsing conditions such as osteoarthritis, diabetes, obesity, infertility and depression.

Goals of Ttreatment

Early in treatment, patients should be encouraged to document their goals. Apart from avoidance of the withdrawal syndrome, these objectives usually include an end to injecting, regularising finances, avoiding the risks of street drugs, obtaining or maintaining employment, restoring relationships, improving self-esteem and in many cases, as a means to becoming drug-free in the longer term. While these achievements are all consistent with good medical practice, this should not be taken to justify unlimited supply of methadone to all who ask for it. Limit-setting by the therapist is also important.

There are other more obscure reasons for joining methadone treatment such as a criminal on the run who is likely to be jailed when caught, or as a condition of sentence in a legal judgement. Very occasional applicants are not narcotic users, but are attempting to give up alcohol or other drug habits, in the usually erroneous belief that methadone may assist.

If the patient's and the doctor's goals are in continuing conflict during treatment, a resolution must be sought. The patient should be given an opportunity to respond to the situation.

One approach is to use "I - messages" such as "I feel uncomfortable that Iam not helping you to achieve your goals". With no satisfactory response, a second opinion or transfer elsewhere may be considered. Such a situation occurs where a patient continues to deal in illicit drugs near the treatment service. Candour should not be rewarded with an indefinite supply of methadone.

A small group of patients has been on and off narcotics many times. While off narcotics, the patient may exhibit anti-social tendencies such as drinking, criminality, violence, gambling and other self-abuse behaviour. Although not having a current opioid habit, these exceptional patients may benefit from methadone treatment, but with suitably modified goals.

Other recidivists sometimes apply for treatment when released from jail. Such a request for methadone treatment can be a mature and appropriate decision to avert a return to previous harmful habits. For such patients, short-term abstinence may not be the highest priority goal.