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
