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A description of methadone and the goal of methadone maintenance treatment mmt

Methadone hydrochloride is a synthetic opioid pain-killer. In New York in the 1960s, Dole and Nyswander [ 12 ] examined the ability of different prescribed opioids to manage heroin dependence, and reported that they found that methadone was most suitable to the task. They believed that long-term heroin a description of methadone and the goal of methadone maintenance treatment mmt caused a permanent metabolic deficiency in the central nervous system and an associated physiological disease, which required regular administration of opiates to correct the metabolic deficiency [ 1 ].

Methadone maintenance thereby became a treatment option for opiate dependence. It involves the daily substitution of one opioid drug with a long half-life methadonefor a short-acting and usually injected opioid drug heroin. The aspects of methadone that have led to its use as a substitute drug for heroin include the following: At the basis of methadone maintenance treatment MMTand all opioid replacement therapy, is the observation that opioid analgesics can be substituted for one another.

The cross-tolerance between methadone and heroin means that a person tolerant to heroin will also be tolerant to a dose-equivalent amount of methadone [ 3 ]. Cross-suppression between heroin and methadone allows methadone to prevent or reverse withdrawal symptoms, and thus reduce the need for the person to use illegal heroin [ 3 ].

Orally administered methadone remains effective for approximately 24 hours, requiring a single daily dose rather than the more frequent administration of three to four times daily which occurs with the shorter-acting heroin [ 4 ].

Methadone accumulates in body tissues, being released as the blood concentration falls, apparently buffering serum levels and minimising withdrawal and sedative effects [ 5 ]. Higher doses of methadone can "block" the euphoric effects of heroin, discouraging illicit use and thereby relieving the user of the need or desire to seek heroin [ 6 ]. This allows the opportunity to engage in normative activities, and "rehabilitation" if necessary.

Methadone is typically administered orally, reducing the health risks associated with injecting. It is quite a safe drug when administered in correct doses, and the side-effects are not significant [ 7 ], especially when compared to the adverse effects of continued illicit drug use.

It is the drug substitution that has made methadone maintenance treatment MMT the subject of much controversy, debate, and misunderstanding, and which has ensured that it has become the most thoroughly studied of all of the interventions for illicit drug dependence [ 8 ].

Methadone maintenance treatment is differentiated from methadone-assisted detoxification, as maintenance implies long-term stabilised dosing of methadone. It is recognised that the long-term dosing may be for an indefinite period or for a substantial number of years with the view of eventual abstinence, although this is not a necessary goal. The differing conceptualisations of the use of methadone maintenance have differing underlying rationales for use.

Where an abstinence goal is seen to be appropriate, conceptually the mechanism whereby methadone maintenance exerts its effects is that it allows the user to develop a life free of the need to seek opiates allowing the development of a social network, employment, etc.

Where long-term maintenance is the goal, methadone is considered by some to act to correct a permanent underlying pathology, in much the same fashion that insulin is used in the case of diabetes mellitus. Top of page 4. The adoption of harm reduction as a goal has also had an effect on the goals of methadone maintenance treatment. This has been reinforced by the advent of epidemic human immunodeficiency virus HIV infection rates among injecting drug users in some parts of the world [ 9 ]. Accordingly, the national methadone policy has incorporated harm reduction as a major goal of methadone maintenance.

More recently, the recognition of the high prevalence of other infectious diseases such as hepatitis B and hepatitis C has come to be seen as an important issue in the care of injecting drug users. It is clear that there are a number of goals that treatment might attempt to achieve sometimes to differing degrees depending upon a number of factors including the type of intervention involved and the perspective on drug use whether the user, the clinician, the community or the health bureaucrat.

There has been a description of methadone and the goal of methadone maintenance treatment mmt recent tendency in the prevention and treatment of alcohol-related problems to accept more limited and realistic goals of treatment such as limiting consumption below agreed levels or reducing the degree of risk of certain patterns of illicit drug consumption by aiming to change only the mode of administration.

To date, the status of these more limited goals remains controversial within the alcohol field. However, the achievement of more limited objectives may be tolerated in the context of persons with serious drug problems provided that other treatment goals have been met satisfactorily. Even for those in drug-free treatment it is likely that there will be continued drug use among some of these individuals, albeit at a reduced rate.

The choice of goal must be realistic in terms of what is achievable with the opioid dependent. An associated objective is the reduction of vertical transmission among HIV infected injecting drug users. HIV risk reduction as a treatment objective often explicitly emphasises public health benefits although not at the cost of a beneficial outcome for the individuals involved.

Clearly the reduction of the spread of HIV is important to all sectors of the community.

4.2 Harm reduction and treatment goals

A hierarchy of HIV risk reduction objectives has been accepted. Variations on this hierarchy exist, but essentially the hierarchy is as follows from least to most desired: Most scales available for measuring physical health are designed for severely disabled clients and do not apply well to this population, although there is a scale recently developed in Australia for the estimation of the health status of opioid users [ 10 ].

Illicit drug users more frequently have infectious diseases including respiratory illness, skin disease, sexually transmitted diseases, and chronic liver disease, hepatitis B, C and D, HIV, infective endocarditis, osteomyelitis, and septicaemia.

  1. At a minimum, the pharmacy should be assured that the institution has established policies which outline the secure handing and safe administration of methadone doses.
  2. Predictors of treatment retention in enhanced and standard methadone maintenance treatment for HIV risk reduction.
  3. The physician practices in accordance with CPSO policies and guidelines and meets the requirements of other relevant legislation for the prescribing, dispensing and storage of methadone in Ontario.
  4. Ball JC, Ross A.

A reduction in the transmission of viral infections closely associated with injecting drug use, such as hepatitis B, C, D, or HIV, is clearly of benefit to individuals as well as the broader society. Additionally, associated with drug use are problems such as poor nutrition, dental caries, menstrual irregularities, complications of injection as a mode of administration, and accidents occurring while intoxicated.

Methadone Maintenance Treatment (MMT) and Dispensing Policy

Specific conditions include pulmonary emboli, cellulitis, thrombophlebitis, and nephrotic syndrome [ 11 ]. Disturbances of mood and personality disorders are said to be extremely common in injecting drug users. Although psychiatric morbidity is common in injecting drug users receiving drug treatment, the extent to which psychiatric problems are a cause or a consequence of illicit drug use remains unclear.

  1. Ann N Y Acad Sci. Since then, a number of correlational studies have suggested a better result is achieved from methadone maintenance treatment if ancillary services are provided [ 25 , 79-83 ].
  2. The role of functional social support in treatment retention and outcomes among outpatient adult substance abusers.
  3. Factors predicting 2-year retention in methadone maintenance treatment for opioid dependence. It is quite a safe drug when administered in correct doses, and the side-effects are not significant [ 7 ], especially when compared to the adverse effects of continued illicit drug use.
  4. Training must be updated at a minimum of every 5 years. Methadone dose is a critical factor in retaining patients in treatment 40.

Whether cause or consequence, these states must be detected via routine screening of those in treatment. Treatment should reduce these problems and promote psychological good health or at least leave the individual no worse off than before in terms of subjective well-being.

There is evidence that for the more severe psychiatric disorders such as serious anxiety disorders, depressive disorders, and psychotic disorders, it is necessary to use well-researched psychiatric interventions. Therefore, it is quite legitimate to include a reduction in criminal behaviour as an important goal of drug treatment.

The relationship between drug use and crime is complex. Although reduced drug use is likely to be accompanied by reduced criminal behaviour, this is not necessarily the case. With improved social functioning, clients should also become more financially independent and, ultimately, detached from the criminal drug-using milieu. The extent to which drug treatment may improve the quality of parenting is an important but relatively neglected field of research.

It is the only treatment for opioid dependence which has been clearly demonstrated to reduce illicit opiate use more than either no-treatment [ 1718 ], drug-free treatment [ 19 ], placebo medication [ 202122 ], and detoxification [ 23 ] in randomised controlled trials.

These trials have been conducted by different research groups in markedly differing cultural settings, yet have converged to provide similar results, suggesting a robust effect. There are three major single group observational studies of MMT effectiveness which involved monitoring client progress, but which included no comparison group [ 242526 ]. They have all shown benefits accruing from MMT, and the convergence of the data from randomised research, quasi-experimental comparative studies and these large scale single group studies provides a level of confidence that MMT possesses robust and replicable beneficial effects.

Deaths from overdosage of methadone have occurred and these are reviewed below. Although precise estimates of the contribution of drug use to mortality are difficult to provide [ 11 ], the major causes of premature morbidity and mortality include accidental overdosage, and infectious disease. Gearing and Schweitzer [ 24 ], in a study of 17,500 clients in the New York methadone program from 1964-1971, found that the mortality rate for methadone maintained clients 7.

The a description of methadone and the goal of methadone maintenance treatment mmt that occurred among those in MMT were less likely to be associated with continued drug use than those which occurred among those who had left MMT or requested detoxification.

Swedish researchers [ 34 ] followed a cohort of 368 heroin-dependent individuals, and assessed mortality over five to eight years. The yearly death rates showed: Of those enrolled in methadone maintenance treatment who died, many of the deaths were related to pre-existing physical diseases and thus were not caused by methadone treatmentand none were caused by heroin overdose.

More recently, Italian research has confirmed the protective effect of MMT. There is also increasing evidence showing that there is an association between being in MMT and lower rates of sharing of injecting equipment, compared to those opioid dependent individuals not in MMT [ 252728 ]. For example, Ball and Ross [ 25 ] showed that injecting drug use and sharing of injecting equipment were significantly reduced after commencement of MMT.

It is now commonplace to assess drug dependence treatments in terms of their ability to prevent or interrupt this epidemic. Unfortunately, the effect of MMT on these diseases has been poorly documented to date, so by necessity the following section focuses on HIV.

The available evidence suggests that being in methadone maintenance treatment is associated with lower rates of HIV infection and risk behaviours associated with injecting sharing used injecting equipment compared with not being in methadone maintenance [ 2538-42 ]. The results of the research are consistent across setting and research groups. According to Ward and his colleagues [ 1546 ], this evidence, in combination with the existing evidence for the effectiveness of methadone maintenance in reducing injecting opiate use, leads to the conclusion that methadone maintenance is an important component of any overall strategy to contain the spread of HIV among injecting drug users, a view that is supported by other influential reviewers of the extant evidence [ 947 ].

  • Retention in publicly funded methadone maintenance treatment in two Western States;
  • The costs of the procedure must be weighed up against the potential benefits, especially in a harm-reduction environment.

The original model developed by Dole and Nyswander [ 16 ] used doses of 50-150 mgs sufficient to block both the withdrawal symptoms and the euphoria from continued illicit use and doses were often above 80 mgs per day.

These doses appear sufficient. Doses in the U. Research on doses lower than 50 mgs produced equivocal results, despite the enthusiastic conclusions of some authors that these low doses were adequate for most clients [ 5758 ].

A careful reading of the research involved reveals that the higher doses are associated with a better outcome [ 13 ]. Additionally, recent research clearly shows the inferiority of low-dose methadone maintenance, compared to moderate doses in terms of heroin use and retention in treatment [ 212225505960 ]. It seems counter-therapeutic that dose level should be kept low, when it is the single best predictor of continued opiate use; the lower the dose the more likely continued unsanctioned opioid use will occur.

Doses should be tailored, and arbitrary rules about low or high doses removed. Client control of dose seems unproblematic [ 616263 ].

Some agencies use tablets, others hypertonic syrup, and some mix methadone in orange juice. Diversion is a risk with syrup and tablets, and these preparations can be injected, and there has long been evidence that diversion does occur [ 64 ].

Methadone can be diverted for several reasons. It can be sold illicitly to supplement illicit opiate users' supplies of heroin, to function as a primary drug of dependence, or to supplement the doses of methadone maintenance clients whose prescribed dose is insufficient.

In the latter case diverted methadone would appear to be dealing with an unmet demand. Of course, diversion which functions to meet a legitimate albeit illicit demand is an argument for ensuring that prescribed doses are adequate to meet clients' needs, and that methadone maintenance treatment is readily available, so that additional opioids are not required to stave off withdrawal symptoms. Research from the United States [ 64 ] with 145 subjects who admitted using illegal methadone indicated that diverted methadone was primarily used to "kick a heroin habit", to "reduce a heroin habit" or "to avoid withdrawal" in the majority of cases.

Methadone was also used when "other narcotics were unavailable", and because it was cheap and easily procured. The extent to which methadone is diverted elsewhere is unclear, as are the reasons for whatever diversion that occurs. However, there is no evidence to suggest that it is a major problem, and it is possible that the uses of any methadone that is diverted are similar to those reported by Inciardi 1977 for his sample.

Introduction

Methods that may reduce the problems of diversion, while normalising clients' lives, include the use of long-acting opioids such as LAAM or buprenorphine, or the use of pharmacy outlet dosing. For unstable clients or where diversion is suspected daily clinic or doctor supervised clinic may be helpful. Research is sparse on these issues. A number of studies have provided evidence that longer retention in MMT is associated with higher doses [ 21222550 ].

Research studies converge to show that retention in treatment is an important goal and result of successful MMT, and that premature termination of MMT is associated with a return to drug use [ 246566 ].

There is some relevant research on the effects of the sudden termination of methadone treatment from natural experiments [ 6667 ]. The research has shown that the ongoing benefits of terminated methadone maintenance treatment are not impressive reinforcing the maintenance aspect of treatmentas there appears to be a high relapse rate to illicit opioid use.

The notion of "curing" the addiction after some arbitrary period of time for the majority of dependent persons is not supported by research. However, a small proportion of opioid dependent clients will leave methadone treatment successfully, and remain opioid free.