methadone maintenance therapy for opiate dependence

Running Head: METHADONE MAINTENANCE THERAPY 1

Methadone Maintenance Therapy

for Opiate Dependence

Anita Ward

Abnormal Psychology

METHADONE MAINTENANCE THERAPY 2

Abstract

Opioid dependence continues to plague society. While

overall heroin related dependence is down in percentages,

opioid dependence created with the use of narcotics is on

the rise. Methadone maintenance (MM) and methadone

detoxification (MD) therapies have been a foundation of

opioid substitute therapy treatment since the 1960s. Over

the years, there has been an abundance of studies which

support methadone therapy as the most effective treatment to

battle opioid dependence. Unfortunately, there continues to

be a high rate of relapse and concomitant illicit drug use

among opioid dependent individuals. Those individuals who

inject opioids are also at great risk for contracting

infectious disease and dying. Although the controversy

surrounding dosing and the side effects associated with

methadone use continue to be examined, a new generation of

research surrounding methadone therapy has turned its focus


beyond traditional therapy which typically focused on

medical reasons for treatment. Instead, current studies

have examined adjunctive therapies such as medical and

psychosocial services, patient self-efficacy, and biological

factors that may have led to opioid dependence. An

integrated approach to methadone therapy may be just what

the doctor ordered.

Methadone Maintenance Therapy for Opiate Dependence

Introduction

For decades, opiate addiction has proven to be an

individual and public health problem for a mass quantity of

substance abusers around the world. Indeed, it is estimated

that at least 980,000 people in the United States alone are


currently addicted to the natural opiate, heroin, and

another staggering 4.4 million Americans abuse or are

dependent upon synthetic opioids such as prescription

narcotics Oxycodone, Dilaudid, and Vicodin, to name a few

(Office of National Drug Control Policy, 2003; Substance

Abuse and Mental Health Services Administration, 2004).

Opioid dependence can lead to premature death and when

injected, has been associated with the spread of infectious

disease such as HIV and Hepatitis B or C. Many addicts also

suffer from liver disease, alcohol abuse, and other physical

and psychological health problems. It is estimated that

5,000 to 10,000 injection drug users die of drug overdoses

every year (Drug Abuse Warning Network, 2003). In an effort

to support their habit, many opiate abusers have submitted

to a life of crime and have had multiple encounters with the

criminal justice system.

The prevalence of opioid addiction is a dilemma that

should not be taken lightly. It has been estimated that the

financial impact of untreated opioid addiction has reached

an astounding 20 billion dollar mark, while social impact of


destroyed families, destabilized communities, increased

crime, increased disease transmission, and increased health

care costs demonstrate its pervasiveness for affected

individuals and society (Farrell et al., 1994). As

discussed during our “Abnormal Psychology” course, the

natural opiate, heroin embodies the problems associated with

opioid dependence. Heroin is less costly than its synthetic

equivalents, yet highly addictive with intense symptoms of

withdrawal developing shortly following its initial use.

Indeed, users of heroin risk addiction and abuse just after

a few short weeks of use and begin a vicious cycle of

increasing their dosage levels. Thereafter, a pattern of

destructive behavior may form which typically affects the

individuals’ physiological, psychological and social well

being.

To combat the unrelenting problem of opioid addiction,

Methadone was introduced into the United States in 1947 by

Eli Lilly and Company (Payte, 1991). Methadone, a synthetic

opioid used medically as a pain reliever and as an anti-

addictive agent for opioid dependence targets the same


opioid receptors as heroin and morphine, and thus has many

of the same effects (Kristenson, Christenson & Christrup,

1995). Used in oral doses, methadone stabilizes patients by

mitigating opioid withdrawal symptoms such as anxiety,

restlessness, aches, and weight loss, while higher doses of

methadone can block the euphoric and sedating effects of

heroin, morphine, and similar drugs and can reduce the

cravings for opiates, a major cause for relapse (Comer,

2011). Therefore, at proper doses, methadone treatment (MMT

or detoxification), a form of opiate substitution therapy

initially introduced during the 1960s, can reduce or cease

altogether, patients’ opioid dependent lifestyles and the

potential health and social hazards associated with opioid

use. Of course, complete abstinence from opioid use is

largely based upon the length of use and the severity of

dependence. In a study performed by Sees et al. (2000) of

179 patients with opioid dependence who were treated with

MMT versus a psychosocially enhanced 180-day methadone-

assisted detoxification program, it was determined that

patients in the MMT program had much better results with a

http://en.wikipedia.org/wiki/Opiate_replacement_therapy


markedly lower use of opiates than the detoxification group

of participants (Sees et al., 2000).

During our class discussion surrounding substance

abuse, we learned that medical authorities have now accepted

drug addiction as a chronic and relapsing disorder that

alters normal brain function and often creates devastating

psychological effects. Technological advancements and

specifically enhancements in medical diagnostic imaging such

as the MRI or PET scan have enabled the medical community to

better understand the effects of chronic opioid use, which

has demonstrated long-term changes in the brain (Comer,

2011). For example, long term heroin users typically

exhibit an altered function of the neurotransmitter,

dopamine. These chemical alterations appear to be involved

in the etiology of dependence (De Vries & Shippenberg,

2002). In that vein, Gruber et al. (2006), in a limited

study of methadone maintenance and its impact on

neurocognition, established a positive correlation between

methadone maintenance and cognitive performance in areas

such as learning and memory tasks (Gruber et al., 2006).


Therefore, methadone treatment programs, mainly MMT, have

proven effective in the management and treatment of opioid

dependence and associated biological and psychosocial

effects that may manifest during opioid use. Alarmingly,

prescription opioids in varying forms have become the

predominant form of illicit opioid use (Fisher et al.,

2005). To society’s detriment, methadone use for chronic

pain management is less regulated and can be acquired via

prescription from a pharmacy, while methadone use for the

treatment of opioid dependency continues to be a closed and

highly regulated system (Rosenbaum, 1995).

Methadone therapy typically involves an outpatient

treatment program, where individuals carry a high degree of

tolerance to opioids and are closely monitored with

witnessed daily dosing. Since methadone therapy is

typically a corrective versus curative treatment for opioid

dependence, it has not escaped a variety of controversy and

debate surrounding its efficacy, proper dosing regimen,

patient program retention, concomitant illicit drug use, and

adjunctive psychosocial therapies, to name a few. A variety


of studies have been conducted to address these and many

other questions pertaining to methadone therapy. Reported

benefits of methadone therapy have been outlined for

decades, but as the fields of medicine and social science

continue to evolve, so do the questions and controversies

surrounding methadone therapy enhancements. To investigate

some of these treatment controversies and enhancements, let

us consider a few studies which centered their research on

the impact of dosing levels on treatment retention and

concomitant illicit drug use, adjunctive medical and

psychosocial services, and non-traditional concepts, such as

consideration of a patient’s self-efficacy during treatment.

Literature Review

The topic of appropriate dosing during MMT and

methadone detoxification therapies has sparked numerous

discussions and studies throughout the medical community.

Although initial methadone dosing usually results in the

administration of 30 milligrams or less based upon

legitimate risks of fatal overdose, most patients require a

dose of 60 to 120 milligrams per day to achieve optimum

METHADONE MAINTENANCE THERAPY10

therapeutic effects of methadone (Yan-ping et al., 2009).

Most schools of thought conclude that compared to those on

lower doses, patients receiving moderate to high doses of

methadone remained in treatment longer, reduced opioid use,

and decreased engaging in deviant behaviors, such as

criminal activities, illicit drug use, and needle sharing.

Strain, Stitzer, Liebson & Bigelow (1993), in a study

of 247 opioid abusers, set out to examine the impact of low

to moderate doses of methadone (0 to 50 mg) in relation to

treatment retention and illicit drug use, as exhibited

during intensive urine testing three times per week.

Specifically, Strain et al. (1993) chose a methadone

treatment research clinic to conduct their controlled

clinical trial comparing moderate to low methadone doses to

methadone free treatment; thus, eliminating the potential

for compromise through confounding factors. A unique

component of this study also examined the effects of

methadone treatment on concomitant cocaine use, which has

become a recognizable and noteworthy trend among opioid

dependent patients.


The eligible and chosen participants consisted mainly

of a male (70%), African American (50%), single (84%),

unemployed (62%), and legally free (72%) population with a

median age of 34 years and an average of an 11th grade

education. All participants had prior experience with MMT

from September 1988 through July 1990 with a mean of two

prior drug treatment admissions for opioid dependence.

Predominantly, the participants engaged in intravenous

heroin use and 47% acknowledged to using cocaine in the 30

days prior to their current methadone treatment. All

participants were admitted into a 182-day (six-month)

methadone treatment program, which consisted of a three

fixed methadone dose schedule (50 mg, 20 mg, 0 mg). The

participants were divided by sex and gender and neither they

nor the clinic staff were privy to the group assignments,

doses, and dosing schedules. During the initial five weeks

of treatment, all participants received a minimum of 35 days

of active methadone followed by 15 weeks of stable

detoxification dosing at 50 milligrams, 20 milligrams, and 0

milligrams per day, respectively. In addition to the


methadone detoxification treatment, participants were also

engaged in group therapy emphasizing relapse prevention

along with individual counseling and onsite medical services

(Strain et al., 1993).

Strain et al. (1993) found that treatment retention

remained high among all participants receiving active

methadone during the first four weeks of treatment, but

remarkably began to deviate between weeks four and eight and

even further between weeks eight and twenty (100 days at the

50 mg dose, 87 days at the 20 mg dose, and 72 days at the 0

mg dose), suggesting that the effects of dosing were at

play. By treatment week 20, retention rates had dropped to

52.4% for patients receiving the 50 milligram dose, 41.5%

for those receiving the 20 milligram dose, and 21% for those

receiving a 0 milligram dose. Not surprisingly, then,

Strain et al. (1993) also found that only those patients who

were administered 50 milligrams of methadone demonstrated a

post treatment reduction in their opioid positive urine

samples from 56.4% at the 50 milligram dose to 67.6% at the

20 milligram dose, and 73.6% at the 0 milligram dose,


respectively. Since concomitant cocaine use is prevalent in

opioid dependent individuals, Strain et al. (1993) isolated

cocaine specific urine samples which painted a similar

picture of methadone dosing effects. Specifically, cocaine

positive urine samples ran at 52.6% at the 50 milligram

dose, 62.4 milligrams at the 20 mg dose, and 67.1% at the 0

milligram dose, respectively (Strain et al., 1993).

Going into this experiment, Strain et al. (1993) were

aware of the effectiveness of methadone treatment, but

treatment related dosing levels remained in dispute. This

is likely in part to methadone toxicity related deaths

following initiation of MMT and detoxification therapies,

along with significant risks of respiratory arrest

associated with high doses of methadone. Despite these

risks, this particular study suggests that dosing is

directly related to a higher success rate of treatment

retention, a reduction in illicit drug use, such as cocaine,

and a reduction in risky behaviors, such as needle sharing

which can lead to the spread of infection diseases. While

Strain et al. (1993) have demonstrated the effectiveness of


methadone therapy at moderate dose levels (50 mg), it would

be beneficial to examine the impact of moderate to high

doses, not only surrounding treatment retention and a

reduction in illicit drug use, but to also consider the

harmful effects that may manifest with the administration of

higher dosing (Strain et al., 1993). Indeed, this study

supports the administration of higher methadone doses in

treatment of opioid dependence. At the time that this study

was conducted, a significant number of methadone treatment

clinics preferred to use lower doses, which calls into

question the true effectiveness and the reasons behind the

resistance in such treatment. Although this study touched

upon the use of group therapy surrounding relapse

prevention, it remained silent as to the degree of impact

that therapy may have had on treatment as a whole.

Undeniably, patients engaged in methadone therapy, have

demonstrated a variety of physical and psychological needs

in additional to their need for traditional methadone

therapy. For example, a one of a kind study performed by

Reilly et al. (1995) considered the psychological concept of


self-efficacy on treatment outcomes in opioid dependent

individuals. The results of their 180 day three phase

methadone detoxification treatment established that self

efficacy influenced subsequent drug use in congruence with

previous behavior. Patient self-efficacy was a predictor

for their illicit opioid use during treatment (Reilly et

al., 1995). Based upon these results, it can be

hypothesized that higher dosing, a regular use of

professional medical and psychosocial services, and our

understanding of psychological constructs like patient self-

efficacy should enhance methadone treatment therapies.

To explore the topic of enhanced methadone treatment

modalities such as medical and psychosocial therapies, Wu,

El-Bassel, Gilbert, Chang & Sanders (2010) in a longitudinal

study of 356 MMT patients investigated whether professional

medical and psychosocial services offered outside of routine

MMT programs would aid in patient treatment outcomes. Wu et

al., (2010) hypothesized that patients receiving additional

services would realize the benefits of such services which

serve to enhance the efficacy of their underlying MMT


program. To test this hypothesis, 356 men enrolled in

Harlem’s one of seven MMT programs were selected following

the satisfaction of the necessary eligibility criteria which

included: 1) being over the age of 18, 2) participating in

MMT for at least three months, and 3) within the last year,

having had a sexual relationship with a woman who was

regarded as girlfriend, spouse, regular sexual partner, or

the mother of the participant’s children. The method of

measurement consisted of a 90 minute in person interview

completed within a week of screening, followed by two

subsequent interviews six and twelve months later.

Participants received nominal monetary compensation

(< $150) for their participation which may have influenced

study participation rates (81% at baseline interview, and

79% at six and twelve month interviews). The interviews

consisted of the gathering of self reported sociodemographic

data (e.g., race, age, employment status), along with self

reported levels of service needs six months prior to

assessment, based upon the participants’ HIV status and life

stressors using the Stressful Life Events Checklist (SLEC)


from the Post Traumatic Stress Diagnostic Scale (Foa, 1995

as cited in Wu et al., 2010), such as serious injury,

homelessness, or physical assault which is often inherent to

living in impoverished urban communities. Fifty-three

psychological distress symptoms were also assessed using the

Brief Symptom Inventory (BSI) (Derogatis, 1993 as cited in

Wu et al., 2010). The independent variable consisted of self

reported data pertaining to the frequency of visits seeking

medical or psychosocial services, outside of the MMT

program, from a physician, mental health professional, or a

spiritual community leader. The dependent variable measured

the participants’ self reported use of illicit drugs such as

crack, cocaine, heroin, and marijuana during the six months

prior to their assessment using the Drug Use and Risk

Behavior Questionnaire (El-Bassel et al., 2000 as cited in

Wu et al., 2010). Upon collection of all self reported data,

participants were assigned to an offsite services

“recipient” or “non recipient” group. Among the

participants, 105 were assigned to the recipient group,


while the other 251 were assigned to the non-recipient

group.

Wu et al. (2010) found that off-site medical and

psychosocial services enhanced the participants MMT

treatment and increased their chance for success in

abstaining from illicit drug use such as heroin and cocaine.

The beneficial effects of supplemental services were not

only noted during the initial six month measurement, but

also over the entire 12-month period. Specifically,

recipients of supplemental off-site services were more than

two and a half times as likely to abstain from heroin and

cocaine use, and more than three and a half times as likely

to abstain from complete illicit drug use. Therefore, the

results of this study serve to not only support the

hypothesis of Wu et al. (2010), but to also underscore the

importance of considering the patients’ physical and

psychosocial needs, which are likely the underlying cause of

their substance addiction (Wu et al., 2010).

It is important to note, however, that despite a clear

and convincing argument for the use of medical and


psychosocial services as adjunctive therapies to methadone

treatment, this study was not without limitations. For

example, self reported data could lead to bias; especially

with regard to data surrounding illicit drug use. Urine

samples would have been far more advantageous in guiding the

results of this study. Moreover, Wu et al. (2010) fully

acknowledged that the lack of a random assignment could have

created a disparity in the variables being measured.

Lastly, this study was silent with regard to which service

was most helpful, the number of sessions attended by the

participants, and whether the participants were receiving

any on-site medical and psychosocial services in conjunction

with their current MMT program. These factors could have

played a significant role in the outcome of this study and

indeed may need to be reviewed as we consider future

treatment options for a growing population of opioid

dependent individuals.

Conclusion

Studies such as the ones performed by Strain et al.

(1993) and Wu et al. (2010) remind us that opioid dependence


is rampant and will continue to affect society.

Unfortunately, the rise in the use of prescription narcotics

and our constant battle with health care cost containment

measures may perpetuate the crisis. To our benefit,

however, the medical community and society as a whole have

become more accepting of the idea that opioid dependence

likely stems from underlying medical and psychosocial needs

and stressors. As we discussed during our “Abnormal

Psychology” course, factors such as genetic predisposition,

social pressures, and personality characteristics, to name a

few, should be investigated and considered as part of all

methadone treatment. Therefore, unless cost factors become

an impediment to treatment, enhancements to methadone

therapy are bound to occur. Indeed, the studies performed by

Strain et al. (1993) and Wu et al. (2010) give us a glimpse

into the complexity of substance related disorders and

controversies that surround treatment options such as

appropriate and effective dosing, supplemental service

therapies, and treatment type (MMT or methadone

detoxification). For some people, MMT may continue for life,


while others may be able to eventually discontinue MMT and

remain abstinent while preserving a similar level of

function that they attained while on MMT. One aspect that

is clear, however, traditional methadone therapy programs,

be it MMT or methadone detoxification, are less likely to be

successful without consideration being given to patients’

underlying medical and psychosocial factors and needs. As

proven in the study performed by Wu et al. (2010), the

influence of additional services beyond traditional

methadone therapy and our willingness to assess factors such

as cognitive performance or a patient’s self efficacy should

serve to enhance future treatment modalities. After all,

rehabilitation should not be limited to medical treatment,

but must also take into consideration underlying motivators

that led to the dependence in the first place, such as a

biological predisposition, social stressors, and

psychological dysfunction, among other reasons.

Although a new approach toward treatment of opioid

dependence and substance abuse disorders is beginning to

take shape, there is a lot of work to be done in this arena.


Future studies should refine its examinations by focusing on

variables that truly contribute to an individual’s success

with methadone therapy programs. Is one dose more effective

than the other when used in conjunction with psychosocial

services? Is group or prevention therapy more effective than

individual counseling that focuses on cognitive behavior

therapy when used in conjunction with MMT or abstinence

therapy? The integration of multiple therapies to treat

opioid dependence is encouraging, but only time will tell if

treatment success rates improve.


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methadone maintenance therapy for opiate dependence

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