Methadone Maintenance Treatment: The Most Effective and the Most Stigmatized Treatment for Opioid Addiction

            Methadone Maintenance Treatment (MMT) has been at once the most effective and the most stigmatized treatment option for opioid addiction since its discovery nearly five decades ago. It remains the single most effective treatment option for opioid addiction, validated by years of rigorous research and scrutiny, while firmly upholding a simultaneous reputation for contention and controversy among policymakers, treatment professionals, and the general population. Although a modicum of research reveals that methadone treatment is highly effective, safe, and cost-effective, opposing viewpoints are not typically based on science or fact but on emotions and moralistic beliefs including the faulty notion that MMT simply maintains opioid addiction legally and the misguided idea that methadone treatment clinics are introducing crime, drugs, and disease into otherwise benign communities. Combatting the stigma against MMT begins with lifting the veil of misconceptions that has shrouded methadone treatment for decades.

To separate fact from fiction, there must be a clear understanding of what methadone is and what it does. Methadone hydrochloride is an opioid agonist medication that tightly binds to the opiate receptors, producing a stabilizing effect that reduces the craving for opioid drugs and blocks the effects of illicit opioids, should the patient attempt to use any (Drug Policy Alliance, 2006). Because methadone is a long-acting opioid (not a short-acting opioid like heroin or morphine) it has unique properties. When administered in a daily therapeutic dose, methadone does not produce euphoria or sedation and keeps the patient from experiencing withdrawal (NIDA, 2009). MMT does not affect cognitive abilities or motor function, such as the ability to drive a vehicle or operate heavy machinery (NIDA, 2009). Furthermore, MMT treats the persistent, distressing psychological and physiological symptoms that accompany the damage done by opioid addiction: deep anxiety, depression, sleep disturbances, and cognitive deficits including problems with memory and attention (Deglon, n.d; Brecher, 1972).

Despite the persistent belief that MMT patients are addicted to methadone, MMT does not constitute an addiction; it treats addiction. An important distinction has been made by physicians regarding addiction and dependence (NIDA, 2009). While symptoms of addiction include physical dependence, addiction is most markedly and particularly characterized by obsessive thoughts and behaviors associated with acquiring a substance and the compulsion to use the substance despite negative consequences (Butcher, 2010). MMT generates physical dependence upon the medication, but dependence is a characteristic of many medications including insulin and antidepressants (Pennsylvania Association for the Treatment of Opioid Dependence, n.d.) and is not sufficient to warrant a diagnosis of addiction according to the criteria of the Diagnostic and Statistical Manual issued by the American Psychiatric Association (Butcher, 2010; Shirra, 2007).

Although MMT is sometimes referred to as replacement therapy, methadone is not a replacement for illicit opioids; it rather replaces the endorphins that the damaged brain can no longer produce on its own (Deglon, n.d.). Addiction to illicit opioids causes profound and most often permanent changes in brain chemistry (Deglon, n.d.; Pennsylvania Association for the Treatment of Opioid Dependence, n.d.). There is even evidence that similar deficits in the production of endorphins may be pre-existing, causing some individuals to be particularly vulnerable to opioid addiction (National Drug Policy, 2006; Deglon, n.d.). The likelihood that opioid-induced chemical deficiencies are permanent means many methadone-maintained individuals will remain on MMT indefinitely. The acceptance of MMT as a legitimate on-going treatment for chemical deficiencies caused by opioid addiction depends on the acceptance of opioid addiction as a chronic medical disease.

Many physicians and treatment professionals rely on comparisons to help others make the critical connection between addiction and chronic illness. In an article supporting medication-assisted recovery, University of Massachusetts Medical School physician Jeffrey Baxter asks his fellow physicians to imagine if diabetics were treated like recovering opioid addicts on maintenance therapy:

“When your blood sugars or dietary habits are poorly controlled, you are sent to a 5 day sugar detoxification program, or 30-day rehabilitation program, and then considered cured. What if your doctor stopped your insulin when you relapsed to eating sugar again, or even discharged you from the practice for “non-compliance”? What if, after you stabilized your diabetes on insulin, your doctor insisted that you “detox” off of insulin, or told you that your dependence on insulin was just covering up your addiction to sugar?” (Baxter, 2006).         

When compared to chronic diabetes, it seems obvious that patients should not be denied or encouraged not to use the very medication that is saving their lives, but this type of disparate treatment is routine for opioid addicts seeking recovery. Advocacy and awareness are essential to fighting such stigma and misinformation.

Because methadone is a powerful narcotic, its safety is often questioned. Actually, all opioids are non-toxic unless taken in excess (Altman, 2002). However, the cycle of euphoria and withdrawal caused by addiction to short-acting opioids encourages the constant release of stress hormones, which causes critical damage to the immune system (Butcher, 2010). Methadone produces physiological stability, which in turn promotes long term health. In fact, methadone is the only narcotic that does not affect the immune system and is safe for both HIV positive patients and for those with chronic liver diseases such as Hepatitis C (Shirra, 2007).

Women who become pregnant while on MMT or who seek methadone treatment after becoming pregnant have had to deal with some of the harshest judgments and criticisms. However, withdrawal from opioids during pregnancy can trigger preterm labor, so maintenance treatment is encouraged as the safest treatment option for pregnant women. Methadone is safe for use during pregnancy and causes no long term effects to the child (National Advocates for Pregnant Women, n.d.). Babies born dependent on methadone can be safely weaned with no adverse effects and virtually no discomfort; even breastfeeding while on MMT is safe and encouraged (Drug Policy Alliance, 2006).

While many people assume that MMT is expensive for society, this could not be further from the truth. MMT is extremely cost effective compared to the costs of other medications and the costs of incarceration and untreated addiction. It costs around $4,000 per year to keep a patient in MMT. In comparison, keeping a drug offender incarcerated for one year, which our society is quite prone to doing, costs around $20,000 (Shirra, 2007). MMT actually ends up saving $4-5 in health and social services costs for every dollar spent (Pennsylvania Association for the Treatment of Opioid Dependence, n.d.).

MMT has been the most successful treatment option when it comes to reducing or eliminating individual drug use, criminal activity, incarceration, and the spread of disease. In a recently published study conducted by the Baltimore area FBI, crime rate data was analyzed from around area methadone clinics and convenience stores. The investigators found that while methadone clinics had no negative effects on proximal criminal activity, convenience stores could be correlated to an increase in crime (Mullins, 2012). Yet treatment clinics are often targeted by discriminatory zoning ordinances aimed at keeping the clinics out of communities. According to Kerry Wolf, vice president of the National Alliance for Medication-Assisted Recovery (NAMA-R), efforts to alienate a specific group through zoning ordinances against treatment facilities are a violation of the 1991 Americans with Disabilities Act (Mullins, 2012). Groups like NAMA-R are active in education, advocacy, and awareness of medication-assisted recovery and the issues faced by patients and providers. Advocacy groups who know the law and can help patients file grievances and even law suits against discriminatory practices are crucial in the fight for equal rights and parity of addiction treatment in healthcare.

After almost five decades, methadone remains the most effective treatment for opioid addiction; unfortunately, it also remains the most stigmatized. As addiction recovery moves forward into an era of more evidence-based practice, education and awareness of methadone treatment is necessary to prevent further regulations or discrimination that could result in inaccessibility to treatment. Those who oppose MMT argue that methadone is just a legal drug addiction, that methadone clinics encourage crime, that methadone is harmful, and that it costs taxpayers too much money. Each of these arguments has been proven wrong by over 40 years of studies, research, and strict federal regulation and scrutiny of MMT practices. It is time to accept MMT as an effective, legitimate course of treatment for a chronic, debilitating disease.

References

Altman, H. (2002, May 8). The positive effects of psychotherapy on methadone maintenance treatment. Retrieved from All Psych Online: http://www.allpsych.com

Baxter, J. (2006). It's time for physicians to support the maintenance model. Retrieved from http://addictionsurvivors.org/vbulliten/showthread.php?t=12646

Brecher, M. (1972). Why methadone maintenance works. Retrieved from http://www.druglibrary.org/schaffer/library/studies/cu/cu17.html

Deglon, J. (n.d.). Survey of 40 years of methadone substitution treatment. Retrieved from http://www.phenix.ch/IMG/pdf/survey_40_years_substitution_methadone.pdf

Drug Policy Alliance. (2006). About Methadone and Buprenorphine. United States of America: Drug Policy Alliance.

Mullins, J. (2012). Methadone advocate opposes zoning resolution. Retrieved from http://www.facesandvoicesofrecovery.org/resources/in_the_news/2012/2012-4-26-methadone.php

National Advocates for Pregnant Women. (n.d.). Frequently asked questions about methadone and pregnancy. Retrieved from National Advocates for Pregnant Women Frequently asked questions about methadone and pregnancy http://advocatesforpregnantwomen.org/MethadoneFAQ.pdf

National Institute on Drug Abuse[NIDA]. (2009). Principles of Drug Addiction Treatment: A Research-Based Guide. US Department of Health and Human Services: National Institutes of Health Publication.

Pennsylvania Association for the Treatment of Opioid Dependence. (n.d.). Methadone treatment. Retrieved from Retrieved from: http://netsteps.org/uploads/Methadone_Brochure.pdf

Shirra, D. (2007). Medical assisted Treatment. Retrieved from http://www.medicalassistedtreatment.org

             

           

Giving Back

Giving up drugs is a process that takes enormous time and energy, not just from you but also from those that have helped you to get clean and stay clean. There often comes a point in recovery where you may feel the need to help others who struggle with addiction. Giving back is a natural part of bettering yourself. It's a natural progression from self-actualization to self-transcendance.

You don't have to be a 12 step sponsor to practice giving back. There are many ways to give back. You simply do what feels right and natural to you.

Like raising awareness, giving back can take many forms. In fact, raising awareness in itself is an essential aspect of giving back. Raising awareness for addiction and medication-assisted recovery helps other addicts by paving the way for better, more accessible treatments and helping to lessen the stigma that keeps so many suffering addicts from seeking help. If  you've progressed to a place in your recovery where you want to give back the support you have recieved, raising awareness is a great place to start. You can read about ways to raise awareness in my former post called Raising Awareness.

Volunteering your time to a local program or treatment facility is another,  more direct way to give back. You can look into your local programs and offer your time to one that appeals to you. There are detox centers, outreach and prevention programs, needle exchange programs, mobile units, and many other programs that need the assistance of dedicated volunteers to function.

Substance abuse counseling is a way to give back while making a living. Counseling addicts is stressful and often thankless, and the burnout rates for addictions counselors are among the highest (about 5,000 vacated counselor positions need to be filled each year). Drug and alcohol counselors are often overworked and underpaid, but it is also a calling for many dedicated people who want to make a difference. For them, counseling is rewarding in many ways. When a client relapses into active addiction, it isn't seen as a failure. A good counselor knows a seed of knowledge has been planted that the addict can cultivate when he or she is ready for recovery. Positivity is essential when dealing with addiction, as with any chronic disease.

Many programs and treatment facilities are utilizing a peer support model as a means to provide added support, especially to those clients who have trouble succeeding in the traditional counselor-client relationship. Peer support programs work on the principle of one addict helping another, as equals, which has been overlooked in recent years as more and more non-recovering people have enetered the field of substance abuse treatment. The growing success of these programs reiterates the importance of the peer relationship in recovery and re-invigorates the idea that a recovering addict's experience can be an invaluable tool for a fellow addict in need.

Giving back is an opportunity to make a difference in someone's life and a chance to remember where we came from. In the case of drug addiction, straying too far from our past can jeopardize our future. No matter how many years we have been sober, we are only one fix away from active addiction. Looking at someone in active addiction with digust or condescendence is a tell-tale sign that we have forgotten we came from. Knowing where we came from allows us to avoid repeating history and help others with true empathy.

Giving back is also (and perhaps best) accomplished by becoming a positive, productive member of society, by being the best person you can be.

Opiate Addiction: Symptom of a Pre-Existing Condition? (Including excerpts from Dr. Jean-Jacques Deglon's Survey of 40 Years of Methadone Treament)

Mainstream science is catching on to what many opiate addicts have known all along-- that for many people, opiate abuse may simply be the most obvious symptom of a pre-existing biological dysfunction of the brain. Many opiate addicts report having persistent feelings of depression, anxiety, and other psychological symptoms long before drug use. The discovery that heroin made them feel "normal," even for a short period of time, precipitated the cycle of addiction, of trying to feel good all the time by administering more opiates (and eventually administering more and more opiates just to avoid withdrawal). Dr. Jean-Jacques Deglon, author of the report A Survey of 40 Years of Methadone Treatment, describes this process:

The near miraculous psychological change described by many of our patients with

psychological difficulties, when they first use heroin, strongly contrasts with the usual

indifference of patients having received morphine in hospital and who never felt the need to

continue once outside. For the former, it is as though all their lives they had seen only in

black and white and that, with opiates, they could at last see in colour. Their determination to

maintain, no matter the cost, this better quality of life is understandable.

Today, new genetic hypotheses are suggested. Some subjects could suffer genetic defaults from birth. Particularities involving certain genes would entail the dysfunction of certain chemical neuromediators of the brain or their receptors (50, 52). These subjects would then also be particularly sensitive to the effect of drugs and more prone to develop an addiction. Adolescents with psychiatric disorders, such as borderline personality disorder, depression, psychotic symptoms, obsessive-compulsive disorders or hyperactivity with attention and concentration deficit, feel better on a psychological level, at least at first, with heroin, and are then tempted to perpetuate that appeasement.

The unique imbalances experiened by opiate addicts have been historically impossible to correct:

The relative inefficiency of antidepressants and neuroleptics in regulating this state of deficiency compared to the “miraculous” action of substitution medication, that often normalises observed disorders in a few hours, enforces the medical hypothesis of a disturbance in the functions of the opioid and dopaminergic systems (20, 21, 22, 55). (Deglon)

A heightened stress response, hypervigilance, depression, anxiety, asthesia, anhedonia, and sleep disturbance are some of the symptoms caused by these imbalances. Doctors have tried using a host psychological drugs, shock therapy, and even lobotomy to correct the dysfunctions and stop addicts from using to no avail. It seems the only thing that corrects the imbalance is an opiate, but short-acting opiates like morphine fail to stabilize patients. They only create the familiar cycle of euphoria and withdrawal and foster the continued obsession and compulsion that accompanies addiction. Methadone changed all that in the 1960s with Dole and Nyswander's ground-breaking study:

Treating heroin addicts with methadone substitution began in the USA in the sixties after the almost systematic failure of psychotherapies and short term weaning programmes. Prof. Vincent Dole, specialist in metabolic illnesses at Rockefeller University of New York, successfully tested the use of methadone, a substance synthesised by the Germans during the Second World War for morphine withdrawal.The first clinical results are remarkable. Heroin addicts on methadone remain normal, without euphoria or withdrawal, abandon delinquency and are able to reintegrate themselves on a professional and personal level.

Although many opiate addicts may have been born with these genetic dysfunctions, long term heroin addiction also causes biological dysfunctions in the brain.

A state of deficiency is often observed following a fast weaning from heroin or methadone,

more particularly after a long period of addiction (16 to 19). This state is characterised by deep anxiety, sleeping disorders, marked asthenia, fatigue, irritability, low self-esteem, relational difficulties, diminished cognitive functions (attention, concentration, memory), depressive tendencies, etc. This now well defined syndrome can last, in a more or less marked manner, from a few weeks to many months. It sometimes even seems irreversible, evoking a lasting malfunction of complex neurobiological regulation systems in the brain owing to opiate exposure that was either too long or too excessive. The psychological suffering that is brought on by the state of deficiency associated with the memory of pleasure states set off by the drug easily explains the frequent relapses of drug addicts. The relative inefficiency of antidepressants and neuroleptics in regulating this state of deficiency compared to the “miraculous”action of substitution medication, that often normalises observed disorders in a few hours, enforces the medical hypothesis of a disturbance in the functions of the opioid and dopaminergic systems (20, 21, 22, 55). (Deglon)

 The dysfunctions caused by long term opiate addiction are similar to the proposed pre-existing dysfunctions, making a case for long term methadone maintenance rather than a prolonged weaning process with total abstinence as the ultimate goal.

 The relapse rates of methadone maintained patients have caused a sense of alarm-- that the failure to get off methadone is somehow attributed to the "strong-hold" of methadone and not to the underlying biological processes that have been profoundly damaged by many years of opiate addiction. Subscribers to this distorted thinking tend to view methadone in the same context as illicit drugs, rather than viewing it as a maintenance drug that corrects a dibilitating imbalance. If the brain fails to heal itself, those imbalances will reappear after weaning, leading to relapse in an attempt to correct the psychological symptoms.

 Moerover, the state of deficiency reactivates reflexes conditioned by heroin, which often entails relapse (23 to 41). In 1979, Newman published a remarkable study (42) with 50 well stabilised patients using a double blind procedure (both therapists and patients were unaware). After 30 weeks of weaning, 90% of patients relapsed or presented a psychological decompensation. Only one patient (2%) was able to be weaned off of methadone without any problems. The results indicated a 98% failure to wean the subjects off of 1mg of methadone a day. This historical study consolidates the medical hypothesis that an important neurobiological basis facilitates and then maintains addiction (20, 36, 43, 44, 45). (Deglon)

Although the disease concept of addiction has been long-established, it has been tainted by the underlying idea (based on the tenets of the 12 step programs) that addiction is a disease of the "spirit" rather than the physical body and that medical treatments are worthless-- that addiction can only be treated by a spiritual program. If addiction is to be treated as a medical disease, it must be accepted as a disease like any other (that happens to manifest in a unique way). Some addicts can abstain from drugs without the use of a stabilizing medication, but many, who suffer the psychological consequences of brain dynfunctions caused by their addictions, must utilize a medical therapy such as methadone or buprenorphine. This is in no way meant to undermine the importance of psychological therapy and holistic treatment, but to encourage their use in combination with medical treatments. In many cases it is absolutely necessary to biologically stabilize the patient before other treatments have a chance of being successful.

For the last 40 years substitution treatments have proven their efficiency. They have enabled hundreds of thousands of drug addicts in the world to avoid psychological and physical decline as well as fatal outcomes by stabilising them in a lasting fashion and returning to them a sometimes exceptional quality of life. On the other hand, even a very progressive stop in the substitution treatment often entails a loss of this quality of life, psychiatric problems and relapse into alcohol or drugs - this particularly in patients with psychological disorders underlying the addiction. For them, the drug must be understood as an attempt to self-stabilise psychological suffering that, to the professional, seems more and more related to genetical neurobiological dysfunctions. The substitution medication then acts as a corrector of the biological defect that corresponds to a chronic illness. For these patients, substitution treatment must be considered as a medical treatment that rectifies a natural imbalance and that must be maintained over an unlimited amount of time as, for example, must insulin for a diabetic or treatment for an epileptic. (Deglon)

So, posing a chicken-or-egg question is really not important when it comes to methadone treatment, since long term opiate addiction also causes the same problems scientists believe may pre-exist in some addicts. The important piece is to look at methadone as a stabilizing medication for treatment of a chronic medical disease. Attempts to wean must be done carefully and with an open mind to the possibility that it may not be an option for some. The decision to wean must be an informed decision made between a patient and his or her physician, not a decision made lightly to appease friends and family or made in response to the percieved hassles of going to a regulated treatment clinic.

It is therefore of the utmost importance to carry out a complete evaluation in order to be able to identify medical, psychological, affective, social, familial and professional problems involved as pre-existing or secondary factors of the addiction and thus to offer specific therapeutic responses. This evaluation also enables an eventual weaning.To conclude, the most important thing is to enable each heroin addict to have immediate access to a form of therapy that suits him - or to many if necessary - so that he may find a good medical and psychosocial equilibrium as soon as possible and maintain that quality of life in the long term. Substitution programmes have proven these last forty years, to be the most efficient answer to these expectations. (Deglon)

Here is a link for anyone interested in reading Deglon's report in its entirety (I highly reccomend you do!):

http://www.phenix.ch/IMG/pdf/survey_40_years_substitution_methadone.pdf

Raising Awareness

What can we do to raise awareness about addiction recovery?

First and foremost, if you're a recovering addict, you can lead by example. Show the world what quality recovery looks like. Show the world you aren't ashamed to be in recovery, and that no one should be ashamed to fight this disease and win! This is a battle worth rallying for.

Wear your turquoise! The turquoise ribbon represents addiction recovery and advocacy. Buy a cheap spool of ribbon and wear your colors with pride. Get your family and friends to wear turquoise ribbons too. Get everyone involved in the fight. More people really need to get out there and raise awareness and advocate. If you survived addiction, if your loved one survived addiction, or if your loved one lost the battle, get out there and fight for him or her. We especially have to fight for those who cannot fight for themselves.

Join a walk or an organization. A Pennsylvania organization called PRO-ACT holds an annual recovery walk in Philadelphia to raise funds and awareness for addiction recovery. NAMI (the National Alliance for Mental Illness) holds walks every year in almost every state, and addiction is a mental illness. Join NAMA Recovery (the National Advocates for Medication-Assisted Recovery). NAMA-R actually has a training program you can complete to become a certified Methadone Advocate. Joining an advocacy group gives you a link to other resources and a network of other people fighting for the same cause.

Donate time or money. If you're as broke as I am, then you probably don't have money to donate, but your time is just as important, maybe more so. Volunteering your time to help suffering addicts or to advocate for recovery is essential. If you have the time, volunteer for your local outreach program. Go to your local treatment facility and ask what they need. Rally to collect toiletries for your local detox center or inpatient facility. Help raise funds for your local treatment clinics, or make a donation, and remember that every bit is helpful, and genorosity is contagious.

Keep up on current issues and research. Make sure you know what's going on in the world of addiction recovery. Is your state trying to put limits on assisted treatment? Is there a new evidence-based treatment you'd like to see in local treatment centers? You need to know these things so you can advocate and fight discrimination against addiction recovery. Write to your legislatures and create petitions when addicts are treated unfairly. Fight for parity for addiction treatment. Fight against unlawful zoning ordinances that target treatment clinics. If no one fights, no one wins. We know recovery benefits everyone, not just the addict, but does your community know that? Does your community know it costs taxpayers ten times more to incarcertate an addict than it does to treat them?

Advocacy is so important to addiction recovery. Support really matters, and awareness does make a difference. We can give hope to a suffering addict or help a loved one understand that addiction is a disease. Our voices can stop communities from discriminating against new treatment clinics and help get the funding needed to help addicts recover. Addiction is a serious, chronic disease. It's time we start taking treatment seriously and fight for the quality treatment suffering addicts deserve.



Fighting Stigma, One Day at a Time

Welcome to Assisted Recovery Advocate, a blog about addiction and medication-assisted recovery. I have started this blog as an extension of my Methadone Advocacy Facebook community page in an effort to reach more recovering addicts, their loved ones, and anyone else who is curious about opiate addiction and recovery. My ultimate goal is to dispell the many myths about methadone and buprenorphine (the two drugs approved for the treatment of opiate addiction) and to advocate for recovering and suffering addicts by educating the public about addiction and recovery.

No disease is accompanied by more stigma and controversy than the disease of addiction. In fact, some people still contend that addiction is not a disease at all, but a weakness of will or character, a moral deficiency, or a "spiritual void."  In the case of opiate addiction, methadone is the most successful treatment available, so why do we continue to prescibe 12 step meetings (with a success rate of about 10%) to heroin addicts who are on the brink of death and desperate for treatment that works? Once a severe opiate addict is stabilized on methadone or buprenorphine, he or she can then benefit from therapy or 12-step meetings. One cannot benefit from psychological treatment if the underlying biological issue is not attended to first.

Methadone has been studied and scrutinized more than any other drug, and now, 50 years later, it is still the best treatment for opiate addiction there is. I don't believe methadone and suboxone should be pushed on everyone; methadone especially should be a last resort. But those who choose medication-assisted treatment should be free to choose it, and they should be able to make that choice without shame and secrecy. If you are on methadone or suboxone, don't let anyone tell you that you're "substituting one drug for another" or that you're not really clean. Never let anyone take away your sobriety! You've earned it!

If more and more people find the courage to stand up and say they were saved by methadone or suboxone, then more people will see that medication-assisted recovery IS RECOVERY.