Question 1: Is methadone maintenance treatment effective for opioid addiction?
Answer: Yes. Research has demonstrated that methadone maintenance treatment is an effective treatment for heroin and prescription narcotic addiction when measured by
- Reduction in the use of illicit drugs
- Reduction in criminal activity
- Reduction in needle sharing
- Reduction in HIV infection rates and transmission
- Reduction in commercial sex work
- Reduction in the number of reports of multiple sex partners
- Improvements in social health and productivity
- Improvements in health conditions
- Retention in addiction treatment
- Reduction in suicide
- Reduction in lethal overdose
- Recent meta-analyses have supported the efficacy of methadone for the treatment of opioid dependence. These studies have demonstrated across countries and populations that methadone can be effective in improving treatment retention, criminal activity, and heroin use (Marsch, 1998).
- An overview of 5 meta-analyses and systematic reviews, summarizing results from 52 studies and 12,075 opioid-dependent participants, found that when methadone maintenance treatment was compared with methadone detoxification treatment, no treatment, different dosages of methadone, buprenorphine maintenance treatment, heroin maintenance treatment, and L-a-acetylmethadol (LAAM) maintenance treatment, methadone maintenance treatment was more effective than detoxification, no treatment, buprenorphine, LAAM, and heroin plus methadone. High doses of methadone are more effective than medium and low doses (Amato, Davoli, Perucci, et al., 2005).
- Patients receiving methadone maintenance treatment exhibit reductions in illicit opioid use that are directly related to methadone dose, the amount of psychosocial counseling, and the period of time that patients stay in treatment. Patients receiving methadone doses of 80 to 100 mg have improved treatment retention and decreased illicit drug use compared with patients receiving 50 mg of methadone (Simpson, 1993).
- A systematic review conducted on 28 studies involving 7,900 patients has demonstrated significant reductions in HIV risk behaviors in patients receiving methadone maintenance (Metzger, Woody, McLellan, et al., 1993).
- A randomized clinical trial in Bangkok, Thailand, included 240 heroin-dependent patients, all of whom had previously undergone at least 6 detoxification episodes. The patients were randomly assigned to methadone maintenance versus 45-day methadone detoxification. The study found that the methadone maintenance patients were more likely to complete 45 days of treatment, less likely to have used heroin during treatment, and less likely to have used heroin on the 45th day of treatment (Vanichseni, Wongsuwan, Choopanya, et al., 1991).
- In the Treatment Outcome Prospective Study (TOPS), methadone maintenance patients who remained in treatment for at least 3 months experienced dramatic improvements during treatment with regard to daily illicit opioid use, cocaine use, and predatory crime. These improvements persisted for 3 to 5 years following treatment, but at reduced levels (Hubbard, Marsden, Rachal, et al., 1989).
- In a study of 933 heroin-dependent patients in methadone maintenance treatment programs, during episodes of methadone maintenance, there were (1) decreases in narcotic use, arrests, criminality, and drug dealing; (2) increases employment and marriage; and (3) diminished improvements in areas such as narcotic use, arrest, criminality, drug dealing, and employment for patients who relapsed (Powers and Anglin, 1993).
- In a 2.5-year followup study of 150 opioid-dependent patients, participation in methadone maintenance treatment resulted in a substantial improvement along several relatively independent dimensions, including medical, social, psychological, legal, and employment problems (Kosten, Rounsaville, and Kleber, 1987).
- A study that compared ongoing methadone maintenance with 6 months of methadone maintenance followed by detoxification demonstrated that methadone maintenance resulted in greater treatment retention (median, 438.5 vs. 174.0 days) and lower heroin use rates than did detoxification. Methadone maintenance therapy resulted in a lower rate of drug-related (mean [SD] at 12 months, 2.17 [3.88] vs. 3.73 [6.86]) but not sex-related HIV risk behaviors and a lower score in legal status (mean [SD] at 12 months, 0.05 [0.13] vs. 0.13 [0.19]) (Sees, Delucchi, Masson, et al., 2000).
Patient Status Before and After Methadone Maintenance Treatment–A study by McGlothlin and Anglin (1981) examined patients from three methadone maintenance treatment programs.
Figures 1 through 5 provide the results from all three programs, which illustrate that methadone maintenance treatment is effective in improving patients’; lives in terms of time spent (1) using narcotics daily, (2) unemployed, (3) involved in crime, (4) dealing drugs, and (5) incarcerated.
The left side of each graph describes patient behavior before methadone maintenance treatment, and the right side of each graph depicts patient behavior following methadone maintenance treatment, including the behavior of patients who left treatment before the year ended.
Figure 1 illustrates that the percentage of time using daily narcotics was much greater before methadone maintenance treatment than after (McGlothlin and Anglin, 1981).
Figure 2 illustrates that the percentage of time unemployed decreased after methadone maintenance treatment (McGlothlin and Anglin, 1981).
Figure 3 illustrates that the percentage of days the patient was involved in crime decreased after methadone maintenance treatment (McGlothlin and Anglin, 1981).
Figure 4 illustrates that the percentage of time dealing drugs decreased after methadone maintenance treatment (McGlothlin and Anglin, 1981).
Figure 5 illustrates that the percentage of time incarcerated decreased after methadone maintenance treatment (McGlothlin and Anglin, 1981).
Figure 6 illustrates a typical day for a person who is opioid dependent. Note that the opioid-dependent person generally uses opioids several times each day. Each use causes an elevation in mood: the user feels “high.” This high is followed by a rapid decline in mood and functional state: the user no longer feels high and may begin to feel sick. At the end of the day, or in the morning, the user feels quite sick as the result of opioid withdrawal. Overall, a typical day includes several cycles of elevated and depressed mood and functional state. As an opioid-dependent person uses opioids for a period of time (e.g., weeks to months), that person's level of physical dependence makes it less likely that he or she will experience the high. Continued drug use results from a desire to avoid the depressions and physical symptoms associated with opioid withdrawal.
In contrast, Figure 7 illustrates that a single oral dose of methadone in the morning promotes a relatively steady state of mood and function. This graph also demonstrates that use of an opioid (e.g., injection of heroin) during methadone maintenance treatment has a less intense effect on mood and function than an injection of heroin in active users who are not in methadone treatment. The dotted line in Figure 7 predicts the course of a patient’s mood and function if a dose of methadone is omitted. Dole, Nyswander, and Kreek (1966) found that the decline in mood and function is gradual, not steep.
Figure 8 illustrates that, during the first year after treatment, 41 percent of methadone maintenance treatment patients were no longer addicted to illicit opioids and were not involved in major crime. In contrast, 27 percent who received no treatment were no longer addicted to illicit opioids and were not involved in major crime (Simpson and Sells, 1982).
Twenty-seven percent of methadone maintenance treatment patients had not used any illicit drugs and had no arrests or incarcerations during the year after methadone maintenance treatment. In contrast, 14 percent of those not treated reported no illicit drug use or arrests. Overall, 68 percent of methadone maintenance treatment patients experienced significant improvements regarding illicit drug use and crime in contrast to roughly 41 percent of those not treated.
The Effect of Methadone Maintenance Treatment Duration on Drug Use and Crime– The DARP study also shows that the longer patients stay in treatment, the more likely they are to remain crime free.
Figure 9 illustrates that there is a relationship between how long patients remain in treatment and how well they function after treatment. In this instance, the length of treatment was associated with abstinence from illicit drug use and an absence of crime. Thirty percent of patients who stayed in treatment for more than 12 months abstained from illicit drug use and criminal activity. Twenty-five percent of patients in treatment from 3 to 12 months stopped using illicit drugs and committing crimes; of those who were in treatment for under 3 months, 20 percent abstained (Simpson and Sells, 1982).
Amato L, Davoli M, Perucci C, Ferri M, Faggiano F, Mattick RP. An overview of systematic reviews of the effectiveness of opiate maintenance therapies: available evidence to inform clinical practice and research. Journal of Substance Abuse Treatment 2005;28(4):321-29.
Metzger DS, Woody GE, McLellan AT, O'Brien CP, Druley P, Navaline H, et al. Human immunodeficiency virus seroconversion among intravenous drug users in- and out-of-treatment: an 18-month prospective follow-up. Journal of Acquired Immune Deficiency Syndrome 1993;6:1049-56.
Sees KL, Delucchi KL, Masson C, Rosen A, Clark HW, Robillard H, et al. Methadone maintenance vs 180-day psychosocially enriched detoxification for treatment of opioid dependence. A randomized controlled trial. JAMA2000;283:1303-10.
Vanichseni S, Wongsuwan B, Choopanya K, Wongpanich K. A controlled trial of methadone maintenance in a population of intravenous drug users in Bangkok: implications for prevention of HIV. International Journal of the Addictions 1991;26(12):1313-20.
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