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Table of Contents

Overview

Question

(1)     The language is confusing - drug abuse, drug dependence, drug addiction. What do they mean?
(2)     What causes people to abuse drugs?
(3)     What are opiates?
          How are they used medically, how are they abused?
(4)     What are the characteristics of heroin addiction?
(5)     What are the physical, social, and economic consequences of heroin addiction?
(6)     Why do heroin addicts seek treatment?
(7)     What forms of treatment are available for heroin and other addictions?
(8)     What is methadone treatment for opiate addiction?
(9)     How was methadone treatment developed and established for the treatment of heroin addiction?
(10)   What is appropriate methadone dosing?
(11)   Is methadone treatment medically safe?
(12)   Does methadone treatment impair mental function?
(13)   Is methadone treatment the best treatment for all heroin users?
(14)   What is LAAM therapy for opiate addiction?
(15)   What other pharmacotherapies may be useful in the treatment of opiate addiction?
(16)   As the most researched pharmacotherapy for opiate addiction, how effective is methadone treatment?
          Is the outcome worth the cost?
(17)   What services do methadone treatment programs offer?
(18)   How is success in methadone and other pharmacotherapy treatments defined?
(19)   Does methadone treatment and other pharmacotherapies for opiate addiction help with drugs of abuse?
(20)   Can methadone and other pharmacotherapies be used to taper ('detoxify') persons addicted to heroin and other opiates?
(21)   Who is eligible for methadone treatment?
(22)   What is the customary course of clinical care for a methadone treatment patient?
(23)  How long should methadone or other pharmacotherapy treatments for opiate addiction last?
(24)   How do methadone treatment programs benefit communities?
(25)   How are methadone treatment programs monitored?


The Future - a look at what is to come.


References


Additional Resources


Credits

 





 

OVERVIEW

Over two million Americans have tried heroin, the most commonly abused opiate drug in the United States, and heroin use is on the increase. Statistics suggest that there are about 810,000 heroin addicts nationwide, with 250,000 in New York State, the majority of whom live in and around New York City.

Since introduced for the treatment of heroin addiction more than thirty-five years ago, methadone treatment has saved the lives of tens of thousands of persons throughout the world. Developed in 1964 by Drs. Vincent P. Dole and Marie Nyswander at Rockefeller University in New York City, methadone treatment is now used worldwide by over 30 countries. It is a significant therapy for diminishing opiate abuse and promoting a better quality of life for patients and their families.

For more than three decades, methadone treatment has been thoroughly evaluated and consistently found to be clinically safe as well as beneficial to individuals and communities. Methadone treatment, and other pharmacotherapies for opiate addiction offered through methadone treatment providers, play a pivotal role in:

Today, more than 179,000 persons receive substance abuse treatment and health-related services in methadone treatment facilities across the United States. Many thousands more are treated worldwide. In New York, methadone treatment is the State's most widely used therapy for heroin addiction, with 43,000 citizens in community-based methadone treatment programs throughout the State.

With a rich history and proven record, the value of methadone treatment continues to be affirmed. Regarding Methadone Treatment and Other Pharmacotherapies: A Review provides a unique overview of methadone treatment- its principles, scope, benefits and outcomes, describing how this important modality, and newly evolving pharmacotherapies for opiate addiction, can work positively in the lives of individuals and their communities.

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(1) The language is confusing - drug abuse, drug dependence, drug addiction. What do they mean?

While the terms are often used interchangeably, distinctions are generally made among the terms drugabuse, drug dependence, and drug addiction.

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(2) What causes people to abuse drugs?

The underlying causes of drug abuse involve biological, psychological, and social/environmental factors.

 

 

(3) What are opiates? How are they used medically, how are they abused?

Opiates are derived from the opium poppy plant that are used throughout the world to treat pain and their medical conditions. Synthetic (man-made) opiates are often used as pre-operative anesthesia, or to treat pain associated with surgical procedures or cancer, to alleviate symptoms of opiate withdrawal, and in treating heroin addiction.

Opiate drugs may be taken orally, intranasally, intramuscularly, intravenously, transdermally, or in suppository form. In all forms and routes of use, they are highly addictive; dependence is both physical and psychological. Persons taking opiates as prescribed may experience a sense of tranquility, decreased anxiety, reduced anger, elevation of mood, and a lessening of depression. Opiate drugs are used illicitly to achieve a state of euphoria or "high", and/or as self-medication to relieve depression, anxiety, and stress.

Recent research involving brain imaging suggests that addiciton to opiatesmay be the result of neurochemical and molecular changes in the brain prompted by the prolonged effects of repeated drug use, or based in pre-existing neurochemical deficits.  Medical research has established that for many persons with long histories of use, opiate addiction is often a chronic, relapsing, but treatable condition.

Included among the drugs classified as opiates are: opium, morphine, heroin, codeine, and the synthetic opiates methadone, Demerol®, and Dilaudi®. This review focusses primarily on heroin, the most commonly abused opiate.

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(4) What are the characteristics of heroin addiction?

Heroin addiction involves a combination of physiological, psychological, and social/behavioral characteristics.

Physiological/Psychological Characteristics: The effects of heroin last four to six hours and during the initial period of use, are highly pleasurable (euphoria, pain relief, calming). To continue feeling these desired outcomes, however, increasing amounts of the drug must be used to achieve the same effect. This is known as "tolerance." The user may at first inhale ("sniff") heroin or inject it into skin or muscle, but as tolerance builds, direct injection into a vein (commonly known as "mainlining") often results.

As the addiction develops, the heroin addict requires shorter intervals between doses and increasing amounts of heroin to avoid withdrawal symptoms, which include muscular and abdominal pains, chills, nausea, diarrhea, yawning, runny nose, generalized weakness and insomnia. Even after the acute phase of the withdrawal syndrome is over (48 to 72 hours), individuals  may experience prolonged symptoms, including irritability, insomnia and drug craving, for months after drug use has stopped.

Social/Behavioral Characteristics: As addiction develops, the user's life increasingly focuses on drug-related endeavors, with consequent inattention to daily responsibilities and needs. Basic changes in the user's activities, self-image and relationships usually emerge. Since the addicted person must, with rare exception, deal with a criminal market, a way of life evolves which commonly entails physical and emotional hazards, general deterioration of health and hygiene, and isolation from most non-addiction friends, associates, and family. The short-acting nature of heroin precludes stability in daily living.

"The Clinton Administration's decision to make methadone more accessible to heroin users is a long-needed change in national policy...Decades of experience have shown that methadone treatment is the most effective way to control heroin adiction. Methadone blunts the craving for the opiate, with substantial benefits to society."

 

The New York Times Editorial, October 3, 1998

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(5) What are the physical, social, and economic consequences of heroin addiction?

The White House in its National Drug Control Strategy (February 1995), "The heavy toll drug use exacts on the United States is most easily measured by the criminal and medical costs imposed on and paid for by the Nation's taxpaying citizens. One estimate places the total cost of drug use at $67 billion [per year]. Almost 70% of this is attributable to the costs of crimes; the remainder reflects medical and death-related costs."

Physical Consequences:Heroin abusers often experience extreme deterioration of health. They are at high risk for infections, drug overdose, HIV/AIDS, Hepatitis B and C, sexually transmitted diseases, and tuberculosis.

Social/Economic Consequences: Regular users often have difficulty maintaining concentration and alertness.

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(6) Why do heroin addicts seek treatment?

The impetus to stop heroin use and seek treatment may derive from complete exhaustion and "burnout" from addiction's harsh and demanding lifestyle; or it may be fear of the dangers of street life, or more serious illness. The catalyst may be pressure from family, friends, employers, or the legal system. It can also be the result of repeated unsuccessful personal attempts to stop heroin use, or the reality of personal, family, or economic collapse. Users seek professional help to find support for change, to handle life stress, to break unhealthy connections with drug-related associates and places, to regain a sense of stability, and to repair health and social problems.

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(7) What forms of treatment are available for heroin and other addictions?

There are many models of treatment available to persons addicted to heroin or other drugs.

The largest number of heroin abusers are treated in methadone treatment programs.

"Mere numbers do not reveal the multitude of intractable addicts that had given up on themselves and believed that theu would never have a normal life. Their lives have been restored, family relations rebuilt, and because of methadone, they are now able to achieve their full potential and life goals that were once unthinkable."

 

President, National Alliance of Methadone Advocates, 1999
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(8)What is methadone treatment for opiate addiction?

Methadone treatment provides the heroin addicted person with health, social and rehabilitational services, and medically prescribed methadone to relieve withdrawal symptoms, reduce opiate craving, and allow normalization of the body's function. Methadone treatment has been the most widely studied approach to opiate addiction and has been in use effectively for over thirty-five years.

Methadone treatment programs are staffed by professionals with extensive medical, clinical, and administrative expertise. Patients receive individually prescribed methadone medication from a licensed medical staff member (physician, registered physician's assistant, registered or licensed practical nurse, or pharmacist). Patients routinely meet with a primary counselor (social worker, caseworker, or certified substance abuse counselor), attend clinic groups, and access medical and social services.

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(9) How was methadone treatment developed and established for the treatment of heroin addiction?

The use of methadone to treat opiate addiction was pioneered by Drs. Vincent P. Dole and Marie Nyswander in the early 1 960's at Rockefeller University in New York. At that time, New York City was estimated to have half of the active heroin addicts in the United States. Heroin-related mortality was the leading cause of death among 1 5 to 35 year olds, and a record number of heroin-related criminal arrests were being recorded. The only available treatment - detoxification - was resulting in ineffective outcomes, with 90% or more of opiate detoxification treatments ending in relapse.

Dr. Dole, a senior physician and metabolic disease researcher, and Dr. Nyswander, a practicing psychiatrist with extensive expertise in opiate addiction, recognized that opiate relapse, in most cases, was related to persistent or recurrent drug craving, and that any approach to treatment must first address the craving factor. They theorized that by controlling drug craving through medically supervised opiate replacement, rehabilitation of lifestyle might also be possible. Their work, and that of researchers over three decades, produced dramatic outcomes, showing that when methadone is taken daily at adequate dosages (doses individually based, which ensure constant methadone blood levels from at least 150-200ng/ml, to a peak of 4006OOng/ml):

 

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(10) What is apropriate Methadone dosing?

Methadone is a medication, and like all medications, proper dosing is contingent upon the patient's individual needs. Taken oraly, methadone is rapidly absorbed from the gastrointestinal tract, appears in plasma 30 minutes after ingestion, and peaks one hour later. Methadone is also widely distributed to body tissues where it is stored and then released into the plasma. This combination of storage and release keeps the patient comfortable by preventing opiate withdrawl. As is the case for any other medications (such as insulin or antihypertensives), propermethadone dosing is determined through the doctor-patient relationship, taking into account the patients medical assessment, individual metabolic needs, and other medical conditions and treatments. Attitudes or opinions about methadone dosing that are based on rationale other than scientific evidence on effective dosing detract from the potential value of methadone treatment.

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(11) Is methadone treatment medically safe?

Research and clinical study, particularly the ongoing work of Dr. Mary Jeanne Kreek of Rockefeller University, has demonstrated the unequivocal medical safety of long-term methadone treatment.

Absence of Serious Adverse Effects: When taken under medical supervision as prescribed, long-term administration of methadone causes no adverse effects to the heart, lungs, liver, kidneys, blood, bones, brain, or other vital body organs. Minor side effects associated with methadone treatment constipation, water retention, drowsiness, skin rash, excessive sweating, and reported changes in sexual libido - may occur during the initial stages oi treatment. These symptoms usually subside or disappear as methadone dosage is adjusted and stabilized, as tolerance develops, or as simple medical interventions are initiated. The myth that methadone is physically harmful has been shown scientifically to be unfounded.

Absence of Harmful Medication interactions: No harmful interactions have been noted between methadone and other medicines. Patients with conditions such as HIV/AIDS, hypertension, diabetes, pneumonia, cardiac conditions, cancers, psychiatric disorders, etc., may be treated effectively with prevailing regimens and medications. Coordination of methadone with certain other drugs is necessary. Dilantin®  for epilepsy and rifampin for tuberculosis increase the body's metabolism of methadone and thus prompt the need for methadone dosage increase. Opiate agonist/antagonist drugs (such as Talwin®  and buprenorphine) should not be prescribed for methadone treated patients, as they will produce opiate withdrawl illness.

Safe for Pregnant Women: With proper stabilization in methadone treatment, sexual function normalizes for both men and women in methadone treatment. Women can conceive and have normal pregnancies and deliveries. When properly prescribed for pregnant women, methadone provides a non-stressful, non-eventful environment in which the fetus develops. Because methadone crosses the placental barrier, babies born to female methadone patients are at first physically dependent on methadone, and must be weaned. Successful weaning using Paregoric® is well established and uncomplicated. These children show normal physical, emotional, and cognitive development, comparable to the children of any mother of the same background. The myth that methadone produces abnormalities in fetuses is unfounded.

"...current policy puts too much emphasis on protecting society from methadone, and not enough on protecting society from the epedemic of addiction, violence and infections that methadone can help reduce."

 

Institute of Medicine, 1995

 

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(12) Does methadone treatment impair mental function?

Methadone treatment has no adverse effects on intelligence, mental capability, or employability. Methadone treated patients are comparable to non-patients in their sensitivity to the environment, in reaction time, in ability to learn, focus, and make complex judgements. Study of the long-term effects of methadone treatment on patients' intelligence revealed that after ten years of continuous methadone treatment, standard intelligence test scores were the same or slightly higher than at onset of treatment. Further, methadone treated patients do well in a wide array of vocational endeavors, including professional positions, service occupations, and skilled, technical and support jobs. Methadone patients are lawyers, engineers, secretaries, truck or taxi drivers, roofers, gardeners, teachers, salespersons, architects, computer programmers, etc.

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  (13) Is methadone treatment the best treatment for all heroin users?

Methadone treatment was developed for persons with significant histories of heroin addiction. It is not appropriate for individuals who use heroin occasionaly, but are not, or never were, physically dependant on heroin. Methadone never was intended to be a treatment for all drug abuse problems.

 

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(14) What is LAAM therapy for opiate addiction?

In 1996, the New York State Office of Alcoholism and Substance Abuse Services announced approval for the use of Levo-Alpha Acetyl-Methadol (LAAM), a longer acting opioid agonist medication for use in the treatment of opiate addiction within licensed and approved methadone treatment programs. LAAM was approved by the United States Food and Drug Administration in 1993 after its safety and effectiveness were documented in clinical trials involving over 6,000 patients. Like methadone, LAAM blocks the euphoric effects of heroin and dramatically reduces the craving for narcotics. More importantly, patients now have a choice of treatment medications, giving them greater input into their treatment and rehabilitation. Each LAAM dose lasts between 48 to 72 hours, and for some patients as long as 96 hours. Its use allows patients to visit the treatment clinic less frequently, bringing more freedom to work, attend school and parent children. Until more information is available, LAAM is presently not recommended for pregnant or nursing women, persons under 18 years of age, or access to treatment for many persons whom daily pharmacotherapy served as a barrier to treatment.

 

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(15) What other pharmacotherapies may be useful in the treatment of opiate addiction?

Naltrexone, a non-addicting long-acting narcotic antagonist, was approved by the FDA in 1985, for the treatment of opiate addiction. It is effective from 1 to 3 days depending on dosage level, and it blocks the euphoric effects of heroin and other opiates. Thus far, research has demonstrated that naltrexone may be most helpful in preventing opiate relapse once an abstinence state has been acheived.

Naloxone is also a narcotic antagonist, blocking the effects of opiate drugs, but has a relatively short duration of action. It is used as an 'antidote' in treating opiate overdose by rapidly reversing the effects of opiate drugs.

Buprenorphine, while not yet approved for the treatment of opiate addiction, is another medication being carefully studied. Early clinical findings suggest that buprenorphine, a partial opiate agonist, is safe and produces few side effects or withdrawl symptoms. The National Institute on Drug Abuse, where significant research on new pharmacotherapies for opiate addiction is currently based, is continuing its study of the usefulness of buprenorphine.

 

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  (16) As the most researched pharmacotherapy for opiate addiction, how effective is methadone treatment? Is the outcome worth the cost?

Methadone treatment has positive outcomes for the individual and for the community. It has been found to be highly cost-effective. The Institute of Medicine² has concluded that "methadone treatment pays for itself on the day it is delivered, and posttreatment effects are an economic bonus."

Reduction in Heroin Use: Studies of methadone treatment have found dramatic declines in heroin use after admission to methadone treatment³, and further declines as patients remain in treatment&sup4;. Variations in policies limiting methadone dosage in some areas of the United States adversely affect discontinuance of heroin use.

Reduction in Criminality: Methadone treatment is associated with reduced criminal activity, and decreases in criminal behavior are greater the longer a person is in treatment.

Reduction in Risk of HIV/AIDS: The relation between intravenous (IV) drug use, needle sharing and HIV/AIDS exposure is well documented. Methadone treatment is its pivotal role in reducing the spread of HIV/AIDS.

Methadone Treatment is Cost-Effectfve: By providing opportunities for patients to be free of heroin addiction, improve health and social productivity, and reduce criminality and risk of exposure to HIV/AIDS, methadone treatment effectively reduces economic and social burdens the community at large would otherwise bear.

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(17) What services do methadone treatment programs offer?

Most methadone treatment providers offer an array of health, social, and human services, tailored to meet individual patient needs. Methadone treatment programs often function as a patients' "primary health care provider," where general health problems are diagnosed and treated on-site or by referral to specialty care facilities. While programs differ in the level and scope of services offered, today's methadone treatment programs offer medical and social approaches well beyond providing methadone medication. Many programs include a range of the following services:

Health Care:

Social and Human Services:

Mental Health Services:

Educational and Vocational Services:

Assistance for Children and Families:

HIVIAIDS Casework:

Prison-Based Methadone Treatment.

Medical Treatment:

 

 

(18) How is success in methadone and other pharmacotherapy treatments defined?

The primary goals are to help addicts cease heroin use and lead more stable, productive lives. But, as knowledge about heroin addiction and effective treatment practices has grown, so too have the objectives of most methadone treatment programs, which also aim to: