Methadone Treatment: Safe, Effective Management of the Painkiller Addiction Crisis
by Drug TreatmentQCS & KCTS
We are facing a tsunami of painkiller addiction that will flood our criminal justice, health care, behavioral health, and social services resources. Illicit online pharmacies have made prescriptions cheap and easy to acquire, fueling a massive wave of addiction that we actually have not seen yet. SAMHSA estimates that over 5% of the nations population, 12 years and older, are using painkillers, no where more prevalent than the heartland with Oklahoma leading the nation at 6.7%.
Opioid addiction used to be thought of as primarily heroin addiction, but that is changing rapidly. The masses currently addicted to prescription painkillers have conveniently been able to manage their addiction and manage other aspects of their lives like job and family. However, the Senate has passed the Ryan Haight Online Pharmacy Act and the DEA is closing down those cheap and easy suppliers of prescription drugs.
When that happens this mass of addiction will suddenly become sick and desperate, and a foreseeable progression of consequences will follow. That means increased criminal activity, loss of jobs, which leads to loss of housing, which leads to the break-up of families and increased utilization of social services. 5.5% to 6.7% of the population 12 years and older may be headed toward this foreseeable progression of consequences.
Traditional approaches to substance abuse treatment have proven ineffective in treating opioid addiction, with high relapse rates. These approaches start with inpatient detox. In Oklahoma, according to ODMHSAS, there is a waiting list of 1,000-1,300 for residential substance abuse treatment. Detox and residential treatment are huge bottlenecks to an ineffective approach. Is there anything to stop this tidal wave of destruction?
SAMHSA has identified the evidence-based best practice, Medication Assisted Treatment, Treatment Improvement Protocol 43, as having the best outcomes for opioid addicts. Even better, in most cases, active opioid abusers can be taken directly into outpatient treatment, skipping inpatient detox and preserving jobs, housing, and families. While new generation drugs have been developed, they are very expensive and are not covered by Medicaid and Medicare, and many private health plans.
Methadone has been around for over thirty years in the treatment of opiate dependency and it is a rigorously well-tested medication that is safe and efficacious for the treatment of narcotic withdrawal and dependence. Opiates like heroin and prescription painkillers release an excess of dopamine in the body and causes users to need an opiate continuously occupying the opioid receptor in the brain. Methadone occupies this receptor and is the stabilizing factor that permits addicts on methadone to change their behavior and to discontinue heroin use.
Taken orally once a day, usually in the morning, methadone suppresses narcotic withdrawal for between 24 and 36 hours. Its effectiveness in eliminating withdrawal symptoms makes methadone useful in detoxifying opiate addicts. Methadone is not, however, effective in cases of addiction to other drugs. Methadone reduces the cravings associated with heroin use and blocks the high from heroin, but it does not provide the euphoric rush because of the longer half-life of the drug in the blood system. Consequently, methadone patients do not experience the extreme highs and lows that result from the waxing and waning of heroin and painkillers in blood levels. Ultimately, the patient remains physically dependent on the opioid, but is freed from the uncontrolled, compulsive, and disruptive behavior seen in heroin addicts.
Lifestyle changes can be made that support the maintenance healthy and responsible living. The Oklahoma Department of Mental Health and Substance Abuse Services reports that heroin accounts for only 5% of substance abuse treatment admissions. Yet nearly 26% of those involved with the criminal justice system have addictions to heroin. Addiction to heroin is highly correlated to criminal activity. That type environment effects many areas of living in a manner that is detrimental to the addict and society as a whole. By removing the need to access that element in order to obtain drugs, whether heroin or diverted prescription painkillers, allows the opiate addict to pursue a different course of life that benefits the addict, their families, and society at large.
Withdrawal from methadone is much slower than that from heroin. As a result, it is possible to maintain an addict on methadone without harsh side effects. Methadone maintenance treatment (MMT) provides the heroin addict with individualized health care and medically prescribed methadone to relieve withdrawal symptoms, reduces the opiate craving, and brings about a biochemical balance in the body. Important elements in heroin treatment include comprehensive social and rehabilitation services.
Is It Safe?
Like any controlled substance, there is a risk of abuse. When used as prescribed and under a physician's care, research and clinical studies suggest that long-term MMT is medically safe (COMPA, 1997). When methadone is taken under medical supervision, long-term maintenance causes no adverse effects to the heart, lungs, liver, kidneys, bones, blood, brain, or other vital body organs. Methadone produces no serious side effects, although some patients experience minor symptoms such as constipation, water retention, drowsiness, skin rash, excessive sweating, and changes in libido. Once methadone dosage is adjusted and stabilized or tolerance increases, these symptoms usually subside.
Methadone is a legal medication, produced by licensed and approved pharmaceutical companies using quality control standards, prescribed by specifically licensed physicians, and administered by specifically licensed clinics, all of which are under close regulatory scrutiny. Under a physician's supervision, it is administered orally on a daily basis with strict program conditions and guidelines. Methadone does not impair cognitive functions. It has no adverse effects on mental capability, intelligence, or employability. It is not sedating or intoxicating, nor does it interfere with ordinary activities such as driving a car or operating machinery. Patients are able to feel pain and experience emotional reactions. Most importantly, methadone relieves the craving associated with opiate addiction. For methadone patients, typical street doses of heroin are ineffective at producing euphoria, making the use of heroin less desirable.
However, there are differences among some clinics' internal policies and procedures that can make drastic differences in the safety of the patient. Below are some of the main considerations:
1. Liquid methadone dispensed onsite cannot be cheeked and diverted.
Studies show that diverted methadone often sold on the streets is responsible for the majority of methadone deaths. Daily dosing onsite allows for clinical assessment of speech, gait, eyes, etc., that prompt urine tests. Urine analysis should include a 12 drug panel and test for adulterants, or masking agents, which are used to flush the system of drug traces. The rampant use of such masking agents makes many tests yield false negatives. Unless the program tests for such adulterants, their patients are at risk.
2. Strict and limited carry-home doses prevents misuse. Carrying multiple doses home allows for:
Self administration of the drug which can result in not taking the drug as prescribed, i.e., overdosing.
Diversion of the drug to the street market. Since methadone potentiates many other drugs, it has a street value.
Supplementation of the methadone regimen with other drugs. Since methadone potentiates many other drugs, this represents a serious risk of drug interaction.
3. Mandatory psychotherapeutic treatment of the underlying addiction.
Not treating the underlying addiction places the opiate addict being maintained a significant risk of relapse while on a medication that potentiates other drugs
4. Accountability to prevent "doctor shopping" and multiple dosing.
Every program should participate in the DEA's Prescription Monitoring Program and fax sole provider letters to all Opioid Treatment Programs in the state to confirm they are, in fact, the sole provider of Medication Assisted Treatment.
Programs that utilize the above safeguards protect the addict from him/herself.
Benefits
Data demonstrates that continuous MMT is associated with several other benefits.
MMT costs about $13 per day and is considered a cost-effective alternative to incarceration (Office of National Drug Control Policy, 1998a) which is a specific alternative to heroin addiction with its fivefold over-representation in the criminal justice system.
MMT more than pays for itself with a benefit-cost ratio of 4:1, meaning $4 in economic benefit accrues for every $1 spent on MMT (COMPA, 1997).
MMT has a significant effect on the spread of several serious diseases such as HIV/AIDS infection, hepatitis B and C, tuberculosis, and sexually transmitted diseases (COMPA, 1997). Heroin users are known to share needles and participate in at-risk sexual activity and prostitution, which are significant factors in the spread of many diseases. Research suggests that MMT significantly decreases the rate of HIV infection for those patients participating in MMT programs (Firshein, 1998).
In a 1998 study the National Institute on Drug Abuse found that, among outpatients receiving MMT, weekly heroin use decreased by 69%. This decrease in use allows for the individual's health and productivity to improve (Office of National Drug Control Policy, 1998a). A life of crime was no longer required to support their habit, and criminal activity decreased by 52% among these patients. Full-time employment increased by 24%. In a 1994 study of drug treatment in California, researchers found that rates of illegal drug use, criminal activity, and hospitalization were lower for MMT patients than for addicts in any other type of drug treatment program.
The Drug Abuse Treatment Outcome Study (DATOS) conducted an outpatient methadone treatment (OMT) evaluation examining the long-term effects of MMT (Hubbard et al., 1997). The pretreatment problems consisted of weekly heroin use, no full-time employment, and illegal activity. Results of the 1-year follow-up showed a decrease in the number of weekly heroin users and a reduction in illegal activity after OMT. There was no significant change in unemployment rates.
In Conclusion
MMT is one of the most monitored and regulated medical treatments in the United States. Despite the longstanding efficacy of MMT, only 20% of heroin addicts in the United States are currently in treatment. The National Institutes of Health Consensus Development Conference on Effective Medical Treatment of Heroin Addiction concluded that heroin addiction is a medical disorder that can be effectively treated in MMT programs. The Consensus panel recommended expanding access to MMT by increasing funding and minimizing Federal and State regulations. Further research must be conducted on factors leading to heroin use and the differences among various users and their ability to end opiate addiction before the demand for heroin addiction treatment can be effectively met by increased MMT availability.
Cummings is the Clinical Supervisor for one of three tribal owned Opioid Treatment Centers in Oklahoma treating both Native and Non-Native adults.
Oklahoma City 405-672-3033
Tulsa 918-835-3017
Miami, OK 918-542-1786
Find out more about methadone treatment
Article submitted Friday, January 23, 2009 & read 4 times.
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