Is Methadone an Effective Treatment for Opiate Addiction?

Preamble:

We have put together a compilation of articles we believe will be helpful in understanding whether methadone is an appropriate treatment for heroin addiction which has been steadily on the increase. We have started with an introduction outlining what is the problem, who it affects, the pros and cons of each drug, etc. In the second portion, we have included statistics we believe are important for backing up your article. We further explore safe spaces and the advantages and disadvantages of these areas. The last portion, we discuss heroin vs. methadone, the effects on the body and mind, as well as if this is successful. We conclude with whether methadone is or is not an effective treatment for opiate users.
Why Is Heroin Abuse Rising While Other Drug Abuse Is Falling? (n.d.). Retrieved April 13, 2015, from http://www.forbes.com/sites/daviddisalvo/2014/01/14/why-is-heroin-abuse-rising-while-other-drug-abuse-is-falling/

In order to provide a more human perspective of addiction, we believe that the video below will be helpful.

Introduction:

Methadone:

In Germany 1939, Hitler and his regime were looking for a drug that was not as addictive as morphine. After WWII, the United States obtained the rights to the drug and it was soon used as a pain reliever in the United States. It was eventually discovered that it was useful in treating narcotic addiction. By 1971, methadone was being used to treat opiate dependency more widely.

Methadone | CESAR. (n.d.). Retrieved April 13, 2015, from http://www.cesar.umd.edu/cesar/drugs/methadone.asp

What is methadone?

Methadone is a synthetic analgesic drug that is similar to morphine in its effects but longer acting, used as substitute drug in the treatment of morphine and heroin addiction. Methadone is an opioid medication. An opioid is sometimes called a narcotic. Methadone reduces withdrawal symptoms in people addicted to heroin or other narcotic drugs without causing the “high” associated with the drug addiction.

Methadone: Uses, Side Effects & Warnings - Drugs.com. (n.d.). Retrieved April 13, 2015, from http://www.drugs.com/methadone.html

Methadone - Ontario Addiction Treatment Centres. (n.d.). Retrieved April 13, 2015, from http://www.oatc.ca/services/opioid-agonist-program/methadone/

What is heroin?

heroin.jpg

Heroin (diacetylmorphine) is an illegal, depressant drug derived from morphine that binds to opioid receptors in the brain and creates a number of different side effects. Heroin is the most abused, fast-acting and popular of all opiate drugs. It is a powder of either white or brown in colour, or it can be a black, tar-like substance that can be injected, snorted or smoked. It is also known by street names such as dope, junk, horse, mac, big h, black tar, brown sugar, and smack. It is often combined with additional substances such as powdered milk, sugar, starch, quinine or certain other poisons to enhance effects.

Heroin. (n.d.). Retrieved April 13, 2015, from http://www.drugabuse.gov/publications/research-reports/heroin/what-heroin

Heroin prescription and history

This study examines a trial comparing oral methadone to injectable diacetylmorphine, the active ingredient in heroin for the treatment of opiate addiction. The prescription of heroin is a controlled one, Britain’s National Treatment Agency for Substance Misuse stressed that this prescription be used as a last resort for patients who have tried methadone and are unsuccessful. This prescription must only be used when the patient has little to no option. Historically, in Britain from the 1920’s and earlier, heroin was used as “the drug of choice” in treatment, towards the 1960’s, the shift towards methadone begun. Methadone was considered a “medical” drug, this contributed in the shift from doctors writing heroin prescriptions to methadone prescriptions. Currently, the people who are prescribed heroin are few, methadone is less costly.

Berridge, V., PhD. (2009). Heroin prescription and history. The New England Journal of Medicine, 361(8), 820-1. doi: http://dx.doi.org/10.1056/NEJMe0904243

Social Pros and Cons

In 2009, the government of Canada put $1-million into a trial which would provide 200 heroin users in Montreal and Vancouver, heroin in a pill or injectable form what could be called “harm-reduction” therapy. Canada is estimated to have 60,000 opiate addicts and the cost associated with untreated drug use estimated at $45,000 annually. One of Vancouver’s safe clinics called “Insite,” a place where addicts can safely use and access free needles faced being shut down when the British Supreme Court exempted it from the Controlled Drugs and Substance Act. Heroin is a safe drug as long as addicts have their ‘fix’ within a safe dosage and often they are able to conduct somewhat “normal” lives. When addicts are forced to hunt for the drug on their own, it puts them in danger for disease, arrest, homelessness and death. Prime Minister Stephen Harper’s cabinet believes that this is just a way of subsidizing drug users’ habits.

Helping heroin addicts. (2009, Jun 02). Winnipeg Free Press Retrieved from http://search.proquest.com.ezproxy.library.yorku.ca/docview/752232153?accountid=15182

This study views the national register data (in Sweden) for 2,638 opiate users for the period between 2004 and 2008 to determine what factors are associated with using methadone or buprenorphine on doctor’s orders for a year or longer. The studies show that opiate users who were employed were nineteen times more likely to use methadone or buprenorphine to treat their addiction than opiate users who were unemployed, suggesting that there is a connection between employment and methadone or buprenorphine. People who did have a job were likely to medicate against their heroin use showing that they may be more easily socially integrated. An active heroin addict is 20 to 60 times more likely to die a premature death and its use is related with criminal activity and mental illness. In the Nordic countries, methadone and buprenorphine are the main treatment for opiate users. This study concludes that opiate addicts undergoing methadone and buprenorphine treatment, regardless of previous criminal activity, would most likely benefit from being employed.

Nilsson, M., Lundgren, L., & Chassler, D. (2013). Predisposing, enabling and need factors of heroin addicts’ using prescribed methadone or buprenorphine for a year or longer: An exploratory study of drug treatment for heroin addicts in the Swedish welfare system. Nordic Studies on Alcohol and Drugs, 31(2), 175-188. Retrieved April 12, 2015, from file:///C:/Users/Christina/Downloads/nsad-2014-0014.pdf

Statistics

- Heroin is the 3rd most commonly injected drug by street youth in Canada

- Less than 1% of drug charges were related to heroin in Canada

(n.d.). Retrieved April 13, 2015, from http://www.unodc.org/documents/data-and-analysis/WDR2012/WDR_2012_Chapter1.pdf

- The number and percentage of persons aged 12 or older who were current heroin users in 2013
(289,000 or 0.1 percent) were similar to those in 2008 to 2012 (ranging from 193,000 to 335,000 or 0.1 percent for all 4 years) (Figure 2.4). The number of current heroin users in 2013 was higher than the number of users in 2002 to 2005 (ranging from 119,000 to 166,000) and in 2007 (161,000). The number of persons aged 12 or older who were past year heroin users in 2013 also was higher than the numbers in 2002 to 2005, 2007, and 2008 (ranging from 314,000 to 455,000). (See Section B.2.3 in Appendix B for additional discussion of the estimated numbers of past year and past month heroin users in 2006.)

(n.d.). Retrieved April 13, 2015, from http://www.drugwarfacts.org/cms/heroin#sthash.Mb8Elg88.dpbs

Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings and Detailed Tables. (n.d.). Retrieved April 13, 2015, from http://www.samhsa.gov/data/NSDUH/2013SummNatFindDetTables/Index.aspx

Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings and Detailed Tables. (n.d.). Retrieved April 13, 2015, from http://www.samhsa.gov/data/NSDUH/2013SummNatFindDetTables/NationalFindin

Heroin. (n.d.). Retrieved April 13, 2015, from http://www.drugwarfacts.org/cms/heroin#sthash.Mb8Elg88.dpuf

Figure 5.3 Mean Age at First Use for Specific Illicit Drugs among Past Year Initiates Aged 12 to 49: 2013

IMG_7569.GIF


Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings. (n.d.). Retrieved April 13, 2015, from http://archive.samhsa.gov/data/NSDUH/2013SummNatFindDetTables/NationalFindings/NSDUHresults2013.htm#fig7.2

In 2013, there were 169,000 persons aged 12 or older who had used heroin for the first time within the past 12 months. This estimated number in 2013 was similar to the numbers in 2002 to 2005 and from 2007 to 2012, but it was higher than the number in 2006 (90,000). The average age at first use among recent heroin initiates aged 12 to 49 in 2013 was 24.5 years, which was similar to the 2012 estimate (23.0 years).

Figure 7.2 Specific Illicit Drug Dependence or Abuse in the Past Year among Persons Aged 12 or Older: 2013

chart7.2.gif

Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings. (n.d.). Retrieved April 13, 2015, from http://archive.samhsa.gov/data/NSDUH/2013SummNatFindDetTables/NationalFindings/NSDUHresults2013.htm#fig7.2

The number of persons aged 12 or older who had dependence or abuse of heroin in the past year was 517,000.

People in Methadone Treatment

There are more than a quarter of a million Americans enrolled in methadone clinics, who are participating in methadone replacement or involved in methadone maintenance. The overall effectiveness of methadone maintenance is clearly demonstrated in its success rate. Results show that since admission, and with the help of methadone detox clinics:

• 95.5% of participants reported a decrease in high-risk behaviour
• 80.0% of participants reported to be abstaining from alcohol and
• other drugs;
• 84.1% reported an improvement in housing conditions;
• 61.4% reported an improvement in employment status;
• 84.1% reported a decrease in criminal behaviour and
• 81.2% reported an increase in family support

Methadone Clinics - Maintenance. (n.d.). Retrieved April 13, 2015, from http://novusdetox.com/methadone-clinics-maintenance.php
(n.d.). Retrieved April 13, 2015, from http://www.cdha.nshealth.ca/system/files/sites/documents/evaluation-methadone-maintenance-treatment-services.pdf

Safe Spaces

Needles

needles.jpg

Safe spaces are places where people can go to use drugs in a safe environment. Instead of using their own unsanitary needles, these places will provide clean needles.

Addicts shoot up in safe haven in Canada - CNN.com. (n.d.). Retrieved April 13, 2015, from http://www.cnn.com/2013/04/11/world/americas/wus-canada-drug-safe-haven

- InSite is located at 139 East Hastings Street in Vancouver and is North America’s only place where people can inject drugs and connect to health care services — from primary care to treat diseases and infection, to addiction counselling and treatment, to housing and community support
- InSite is North America’s first legal supervised injection site
- Vanvouver coastal health operates and provides funding, senior administrative and health care workers for the facility
- Vancouver coastal health gets a lot of their funding from the BC Ministry of health services
- InSite has 12 injection booths where clients inject pre-obtained illicit drugs under the supervision of nurses and health care staff
- InSite provides clean injection equipment such as:
• syringes
• cookers
• filters
• water
• tourniquets
- There has been 1418 overdoses at InSite between 2004-2010, staff were able to successfully intervene each time
- There have been no fatalities in InSite since it opened
- Research shows that since InSite opened, overdose in the vicinity of the site decreased by 35% — compared to a 9% decrease in the city overall

Insite - Supervised Injection Site. (n.d.). Retrieved April 13, 2015, from http://supervisedinjection.vch.ca

Methadone clinics are established for the dispensing of methadone, a schedule II opioid analgesic, to those who abuse heroin and other opioids. The focus of these clinics is the elimination or reduction of opioid usage by putting the patient on methadone.

Methadone clinics in Toronto:

• Satellite— opiate treatment clinic

Satellite – Opiate Treatment Clinic. (n.d.). Retrieved April 13, 2015, from http://www.breakawayaddictions.ca/satelliteopiate.html

• OATC (Ontario Addiction Treatment Centres)

Methadone - Ontario Addiction Treatment Centres. (n.d.). Retrieved April 13, 2015, from http://www.oatc.ca/services/opioid-agonist-program/methadone/

• ACT (Addiction Centre Toronto )

ACT - Addiction Centre Toronto. (n.d.). Retrieved April 13, 2015, from http://www.acttoronto.com

Methadone is only available through approve outpatient treatment programs — it is dispensed to patients on a daily basis

Treatment and process

For example at ACT — Addiction Centre Toronto:

• Patients are treated at first with 10mg to 30mg per day, for the first three days; however, if the patient is a high risk patient, they are started with 10mg to 20mg of methadone
• Doses may be increased by 5mg to 15mg every three to four days
• During the treatment, patients are at a higher risk of an overdose if other drugs or alcohol is ingested
• As the body is adjusting to metabolizing the methadone, the patient may feel some withdrawal symptoms from the heroin

ACT - Addiction Centre Toronto. (n.d.). Retrieved April 13, 2015, from http://www.acttoronto.com/content/usingMethadone/stages_of_treatment.html

OATC – Ontario Addiction Treatment Centres bases their program on an outpatient harm reduction model, which includes:

• An initial intake interview
• Medication examination and laboratory tests
• Supervised urine testing
• A signed treatment contract and treatment plan
• Addiction counselling
• Regular medical follow up
• Daily methadone dose
• Post-methadone treatment (i.e. relapse prevention and medication where appropriate)

How does Methadone Work?

Methadone1.jpg

According to webmd.com, “Methadone works on parts of the brain and spinal cord to block the "high" caused by using opiates (such as heroin). It also helps reduce cravings and withdrawal symptoms caused by opiate use. The action of methadone is similar to other synthetic (man-made) medicines in the morphine category (opioids)”.

Methadone for Drug Abuse. (n.d.). Retrieved April 13, 2015, from http://www.webmd.com/mental-health/addiction/methadone

Detoxification is the first step in treating opiate users. Methadone treatments reduces the risk of heroin use, disease transmission and death. Methadone treatments are given once a day orally, its long acting effects can eliminate opiate withdrawal symptoms for 24-36 hours. When given in high dosages, it reduces the craving for heroin as well as blocks the euphoric sensation that heroin gives. There have been studies regarding other drugs that may be helpful in treating heroin addiction, each of them seemingly having their own benefits. However, oral methadone continues to be the best- suited and most popular form of treatment for opiate users.

Ward, J., Hall, W., & Mattick, R. (n.d.). Role of maintenance treatment in opioid dependence. The Lancet, 221-226. Retrieved April 12, 2015, from file:///C:/Users/Christina/Downloads/Role of maintenance treatment in opioid dependence. Waard et al 1999.pdf

Problems with Methadone

The report discusses studies related to the possibility that extended methadone treatment can lead to morphine tolerance. The discussed studies appear to show that long-term methadone users appear to build a tolerance to morphine for the treatment of pain. In one study it was found that “Compared to the control group, these patients were found to experience minimal antinociception, despite greater plasma morphine concentrations. The authors concluded that in patients treated chronically with methadone, conventional doses of morphine are likely to be ineffective in managing acute pain” (Eugenio, 2004, p. 51). This report was geared toward end-of-life care and warned of the danger the effects of extended methadone usage might have on patients requiring pain control during that time.

Eugenio, K. R. (2004). Profound morphine tolerance following high-dose methadone therapy. Journal of Pain & Palliative Care Pharmacotherapy, 18(4), 47-54. doi: http://dx.doi.org/10.1300/J354v18n04_05

This study was done to study the effects of methadone dosage, duration of treatment and the plasma level of methadone and their relation to heroin tolerance. In order to complete the study, Volavka et al used 12 male ex-addicts between the ages of 20 and 37 who were opiate users anywhere between 6 to 22 years as subjects. They were detoxified and for a period of six weeks after detoxification, remained drug-free. A variety of sessions were held in which the subjects were given various doses of methadone, heroin and a placebo. Medical checks were maintained throughout and measurements were taken for a period of 19 days. The study concludes that there were no indications that the methadone dose, duration of treatment and the plasma level of methadone had role in the development of tolerance to heroin, with the caveat that the study was restricted because of the short duration and that further studies could be useful.

Volavka, J., Verebey, K., Resnick, R., & Mulé, S. (1978). Methadone dose, plasma level, and cross-tolerance to heroin in man. Journal of Nervous and Mental Disease, 166(2), 104-109. Retrieved from http://search.proquest.com.ezproxy.library.yorku.ca/docview/616285554?accountid=15182

Acute Effects:

• Acute intoxication is characterized by euphoria and drowsiness.
• Mast cell effects (e.g. flushing, itching) are common, particularly with morphine.
• GI [gastro-intestinal] effects include nausea, vomiting, decreased bowel sounds, and constipation.

Chronic Effects:

• Tolerance develops quickly, with escalating dose requirements.
• Tolerance to the various effects of opioids frequently develops unevenly.
• Heroin users, for example, may become relatively tolerant to the drug's euphoric and respiratory depression effects but continue to have constricted pupils and constipation.
• A minor withdrawal syndrome may occur after only several days' use.
• Severity of the syndrome increases with the size of the opioid dose and the duration of dependence.
• Long-term effects of the opioids themselves are minimal; even decades of methadone use appear to be well tolerated physiologically,
• Some long-term opioid users experience chronic constipation, excessive sweating, peripheral edema, drowsiness, and decreased libido.
• However, many long-term users who inject opioids have adverse effects from contaminants (e.g. talc) and adulterants (e.g. nonprescription stimulant drugs) and cardiac, pulmonary, and hepatic damage due to infections such as HIV infection and hepatitis B or C, which are spread by needle sharing and non-sterile injection techniques.

Heroin. (n.d.). Retrieved April 10, 2015, from http://www.drugwarfacts.org/cms/Heroin#Effects

Conclusion

We are certain that the information above will be helpful in your research on whether methadone is an effective treatment for opiate addiction. Conclusions can be drawn that methadone is an effective treatment for heroin addiction, although there are negative consequences associated with methadone use.

Asha Gonsalves & Alysa Rafael

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