Methadone and Suboxone can be used in opiate/opioid detoxification or as substitute/maintenance medications to replace heroin or other opiates/opioids. Some patients might take these medications for a few weeks or for several months, using it as a bridge to transition to total abstinence. There are also individuals who are not able to achieve and maintain abstinence without it and who take it for years and may stay on it. A common misconception about opioid substitution/maintenance is that although we’re using medication to assist someone to get off the drugs they’re abusing, aren’t we “just replacing one drug with another”? The uninformed (including some medical, behavioral-health, and even addiction-treatment professionals) believe that methadone and Suboxone are just different forms of heroin, or just another opioid, and that one form of addiction is being traded for another. The term maintenance refers to keeping an addict on a safer substitute pharmacological agent in order to eliminate or greatly reduce drug cravings, eliminate the need to engage in criminal and other high-risk activities to get drugs, avoid the pain of withdrawal, and make possible his or her engagement in a more responsible and productive lifestyle. Originally, maintenance therapy was used to treat heroin addicts with methadone. In recent years, Suboxone has joined methadone as a replacement medication, and this option is now available to addicts who use opiates/opioids of any kind, including prescription painkillers. Opioid maintenance, also known as opioid substitution, is a medically managed, physician-supervised process based on the concept of harm reduction. Its primary purpose is to reduce involvement in high-risk activities and decrease serious adverse consequences for both the individual and the community. Its goal is to enable addicts to function at a higher level more quickly. There are huge differences between people who are still caught in the grip of active addiction and those on methadone or Suboxone maintenance/substitution. People on opioid maintenance/substitution are not shooting up heroin or taking Vicodin or other opioids five times a day and stealing or committing other kinds of crime to support their addiction. Often they have jobs, their family situations are more stable, they’re functioning at a much higher level, and they’re not riding a roller coaster of getting high and getting sick due to withdrawal. Medication-assisted treatment and recovery provide the individual with opportunities to effectively address his or her psychological, medical, social, legal, and family issues—impossible in the chaos of active addiction. Methadone Back in the 1960s, the most common treatment for heroin addiction was to have patients go cold turkey or simply stop using heroin and allow all of the pain and other withdrawal symptoms to simply wash through their systems. To help addicts detox from heroin and stay off it, without the excruciating pain of going cold turkey, the medical community developed methadone treatment. The first maintenance drug, methadone was introduced in 1964 after studies supported its effectiveness in fighting heroin addiction. Methadone was a vehicle to help addicts transition away from the lifestyle that went with heroin so that they had a chance to become productive members of society. Most people do drugs to get high, to feel good, to feel euphoric, and that’s certainly true of opiates in the beginning, but most people who have been on opiates for a long time don’t use to get high anymore; they just don’t want to get sick with withdrawal. It’s a different form of addiction, which is why some of the approaches that we’ve used for addiction to other substances, such as abstinent-based counseling strategies and recovery programs, don’t work quite as well for opiate addicts. The relapse rates for opiate/opioid addicts are extremely high, estimated to be as much as 90 percent at six months post-detoxification(12). It’s not unusual for us to detox somebody, provide counseling services, and within one to four months see them again back on heroin, Norco, Vicodin, OxyContin, or some other opioid. It’s true that, as a result of protracted withdrawal, people in early recovery generally don’t feel “normal” for a long time after they have stopped using drugs, but this is particularly true of long-term use of opiates. Opiates/opioids change the way the brain and body react, and people don’t feel normal for a long time after they stop using. When we look at the outcomes of patients on methadone and how well they do at staying free from other drug use, in my experience, about 50 to 80 percent report staying off heroin, compared to the opiate blocker naltrexone, where only 10 to 20 percent of the people using this as their primary path of recovery stay abstinent from other drugs. For opiate addicts who attempt recovery completely drug-free, using detoxification, counseling, twelve-step programs, sober living houses, etc., sustained abstinence is even lower. There are many myths about methadone. Some people say that methadone gets into the bone marrow, rots the teeth, and depletes calcium. The reality is that few drugs have been studied as extensively in humans as methadone has. Hundreds of thousands of people have been maintained on methadone, many since maintenance treatment was developed more than forty years ago. Methadone and methadone therapy are so tremendously misunderstood (for many reasons) that any study indicating such serious side effects would have been massively publicized and almost certainly resulted in ending this form of treatment. As used in opioid maintenance/substitution treatment, methadone is one of the safest medications known. Another myth about methadone is that it was named for Adolf Hitler, and the drug had some connection to Hitler’s Nazi regime as a pharmacological vehicle for controlling people. This is patently untrue. While it is true that methadone was first synthesized prior to world war II by German pharmacologists, it was called Hoechst 10820 or polamidon. Moreover, its properties as a useful medication with which to treat addicts were only discovered well after the war in the United States. Dolophine, the original trade name for methadone hydrochloride, originated in the US, and was not derived from the name “Adolf ” but from the Latin “dolor” (pain) and “phine,” from Morpheus the Greek god of dreams that morphine is named after. Unfortunately, there continues to be a tremendous amount of misinformation and ignorance surrounding methadone. It is absolutely appalling to me, and one of the saddest things I’ve experienced as a physician in the addiction treatment field. I’ve had patients who become stabilized on methadone and are doing well, until the family insists on getting them off “that horrible drug,” and within a week or two they’re back on heroin again. I’ve had judges and parole officers demand that a patient who was stable on methadone get off of it because “it’s just another drug,” and within a month or two he or she has relapsed on heroin. The model for care in the United States has traditionally been “abstinence only” and if you can’t achieve abstinence, “there’s the door.” It’s “our way or the highway.” Patients are told, “You’re not really ready for recovery.” And a lot of people have been told that they’re “not really ready for recovery” simply because they’re not able to remain abstinent without the assistance of medication. The use of maintenance medications is realistic in acknowledging that even though total abstinence is the ultimate goal, not all addicts are ready for it or perhaps even capable of it. Methadone promotes a reduction of HIV seroconversion—the process of going from HIV negative to HIV positive—so people on methadone are less likely to become HIV positive. For people on methadone maintenance/substitution there are reductions in relapse to IV and other drug use and improved social functioning, health, and employment outcomes. Remember that recovery is a process, not an event. So the goal for any pharmacology, whether it’s Prozac or Suboxone or methadone, is not a cure but prevention or reduction of symptoms. In the context of opiate addiction, prevention and reduction of withdrawal symptoms, prevention or reduction of drug craving, prevention or reduction of relapse, and restoration to normalcy of physiological and interpersonal function disrupted by drug abuse. While methadone is far from perfect, it is so safe that it’s the only medication allowed for use in treating opioid addiction in pregnancy. If an addicted woman is on methadone maintenance during her pregnancy, upon delivery, the baby goes through a mild withdrawal syndrome that is easily treated. Methadone is an absolute wonder drug for people who need that kind of help. Think about this: If you detoxed somebody and provided rehab services twenty-three or twenty-four times, and he or she comes in again, do you really believe that you should offer him or her the same treatment for the twenty-fifth time? Or do you think maybe, just maybe, you have an ethical responsibility to try something different? In order to dispense it as an opiate addiction treatment method, providers must be specifically licensed as methadone clinics. That’s why patients on methadone maintenance/substitution have to go to a methadone clinic to get it. New patients are typically required to visit the clinic daily so that they can be observed taking their dose by the dispensing nurse, but, after several months of adherence to the clinic’s regulations, including consistent negative drug screens, they are often allowed to leave the clinic with “take-home doses.” There is considerably less euphoria associated with methadone than with other shorter-acting opiates/opioids, and as a result, the diversion of methadone to others or for sale on the street is rare. Methadone clinics are federally mandated to provide counseling services, either via on-site counseling or through an outside entity. And that counseling has to include HIV counseling. There’s very strict recordkeeping and confidentiality. The point is that the federal government is trying to make these methadone clinics adhere to a higher standard than they have in the past. And government regulations actually mandate the frequency with which methadone clinics must conduct random drug tests on patients. When used correctly, methadone maintenance has been found to be medically safe and non-sedating. Usually about twenty milligrams of methadone is required to block opioid withdrawal syndrome so patients are often started at that dosage. Treating physicians examine the patient, see how he or she is doing, and then gradually raise the dose to the appropriate level to make sure that cravings are being blocked and the patient has an appropriate level of comfort. Sedation from methadone really only occurs in this “induction phase,” when the correct dosage is being determined. Once stable on the proper dose of methadone, patients rarely experience sedation. In comparing the action and effects of methadone and buprenorphine with heroin and other opiates/opioids, there are many notable differences. The onset of methadone or buprenorphine takes about thirty minutes and lasts twenty-four hours—very long-acting. Heroin’s effects are felt immediately, so the user gets an instant rush of euphoria. However, the duration for heroin is only three to four hours (the duration of other opiates/opioids is much less), so users typically require several doses to make it through each day to stave off withdrawal. It’s like being on a roller coaster, going up and down continuously. Because methadone and buprenorphine have such a long half-life, they only have to be taken once a day. You may hear that methadone is more addicting and harder to get off than heroin. This is not precisely the case. Because of its shorter half-life, which results in the need to use it more frequently, heroin has higher addictive potential than methadone. However, it’s true that as a result of its longer half-life, methadone withdrawal does last significantly longer than that from short acting opiates/opioids, including heroin. This contributes to the perception that methadone is more difficult. Buprenorphine Buprenorphine is the active ingredient in both Subutex and Suboxone, and that Suboxone is a much more frequently used formulation because it combines buprenorphine and naloxone, a feature designed to prevent misuse. when you place Suboxone under the tongue, the naloxone part of the formula (the inverse antagonist) is mixed with saliva and is not absorbed. It just passes through the GI tract. But if you grind it up and shoot it up then the naloxone does hit your bloodstream and you experience rapid and severe withdrawal. Suboxone has a number of advantages compared to methadone for opioid maintenance/substitution. It can be prescribed by office-based physicians as long as they apply for a special license from the DeA, thus increasing access to this treatment option for people addicted to heroin or other opiates/opioids. As a partial agonist, the strength of its effect has a ceiling so that after a certain dosage, taking more of the drug does not create more of an effect. It is also less sedating and causes less respiratory depression than full opioid agonists, including methadone. Like methadone, which binds to opiate receptors in the body, buprenorphine eliminates withdrawal and cravings and significantly decreases the potential for relapse. But while buprenorphine binds to opioid receptors, it only moderately activates them—generating limited euphoria compared to other opiates/opioids and reducing its potential to be abused. Although it is not impossible to get high from buprenorphine, even when sold on the street, it is mostly used by addicts to ease withdrawal symptoms when they don’t have access to opioids. How we approach these patients when they “slip” or relapse is very different from the strategy that has been used in abstinence-based treatment programs. In traditional drug rehab programs, if a patient is found doing drugs, he or she is thrown out of the program. In contrast, in medication-assisted treatment and recovery, the proper response to patient drug use is to adjust and perhaps enhance the treatment approach. Treatment professionals explore why patients are doing drugs and potentially modify the methadone or Suboxone dose. It’s a different paradigm and a different treatment philosophy. Conservative estimates are that more than half the people in prison in the United States are there for drug-law violations. Based on that fact, it appears that the way we treat most people with addiction in America is incarceration. The positive impact of opioid substitution/maintenance treatment using methadone and Suboxone in reducing death rates,rates of incarceration, and rates of intravenous drug use and associated infectious diseases is undeniable. Often among the biggest challenges to medication-assisted recovery are the twelve-step programs that can have rigid definitions of what constitutes abstinence and being “in recovery.” There have been times when people on methadone or Suboxone have attended NA meetings and were judged harshly, told that they were not clean or in recovery, and made to feel unwelcome. Ironically, in our society where addiction and addicts tend to be stigmatized, some of the twelve-step programs and groups where ordinarily addicts are fully accepted stigmatize those seeking recovery with the aid of medication. This situation varies based on program and location, and fortunately, slowly this stigma is lessening. But it remains a real obstacle for people on methadone or Suboxone who want to participate in a twelve-step recovery process. Educating people, including those in the addiction treatment and recovery communities, especially, is critical. I’m hoping that the material presented here will be part of that process of expanding the understanding that, for some people, opioid maintenance/substitution is necessary and appropriate. In one class I taught, a student said that she brought this material up in the addiction treatment program where she worked and was told “whoever told you this is an idiot.” Some people, when advised to go to a twelve-step program, may say they “hate twelve-step recovery,” even though they have no actual experience with the program and have never been to a meeting. In other words, such individuals have concluded that they are adamantly against something before they have even looked into it, much less given it a fair chance. Abstinence may be the gold standard in addiction recovery, but not everybody can successfully achieve and maintain total abstinence. Some addicted persons are incapable of strict abstinence-based twelve-step recovery—period. If you have a patient, especially an opiate addict, and he or she is a chronic relapse patient—then as an addiction treatment professional, as a counselor, you need to know about and be able to discuss options besides strict abstinence and twelve-step recovery. We must tailor the treatment to the patient, not to our own biases or belief systems. Remember, if you are an addiction counselor in recovery (and many addiction counselors and therapists are in recovery themselves), this process is about your client’s treatment and recovery, not yours. As an addiction counselor, you need to be aware of other approaches to addiction beyond the abstinence model. It’s important to not let the perfect (strict abstinence) be the enemy of the good (harm reduction approaches that decrease risks in many life areas). New medications and delivery systems are in the research and development pipeline. For example, Probuphine is a long-acting buprenorphine (the active ingredient in Suboxone) implant that has just completed Phase 3 clinical trials. It allows continuous delivery of the medication for six months after a single treatment. Because it eliminates the need for daily dosing, probuphine is expected to improve adherence to buprenorphine (Suboxone) treatment (just as Vivitrol does for naltrexone) and reduce possibilities for diverting or abusing the drug. Other new directions in medication development include vaccines. Addiction vaccines work by stimulating the body to produce antibodies against a drug to effectively neutralize it while it is still in the bloodstream, keeping it from getting to the brain and exerting its rewarding (and damaging) effects. Vaccines hold promise as a novel approach to treating addiction to a variety of drugs including nicotine, heroin, cocaine, and methamphetamine. The roadblock in this approach so far has been the vaccines’ inability to generate a strong enough immune response so researchers are currently focusing on this issue. 10 Mala Szalavitz, “Hazelden Introduces Antiaddiction Medications into Recovery for First Time,” Time, November 2012. http://healthland.time.com/2012/11/05/hazelden-introduces-antiaddiction-medications-in- recovery-for-first-time/ (accessed February 8, 2013). 11 M. Srisurapanont and N. Jarusuraisin, “Opioid antagonists for alcohol dependence,” Cochrane Database of Systematic Reviews 1 (2005). http://www.ncbi.nlm.nih.gov/pubmed/15674887 (accessed January 4, 2013). 12 David A. Feillin, “Buprenorphine: effective Treatment of Opioid Addiction Starts in the Office,” American Family Physician 73, vol. 9 (2006): 1513–14. This blog post is an excerpt from The therapist’s Guide to Addiction Medicine – A Handbook for Addiction Counselors and Therapists – by Barry Solof, MD, FASAM; Published by Central Recovery Press (CRP).