Reprinted from "Drugs in Society", March/June 2004, Alcohol and Drug Foundation of Queensland.
Dr.Andrew Byrne
Methadone is just a drug. When used appropriately it can obtain predictable, positive outcomes for opioid dependent citizens. As with other drugs, when used improperly, unpredictable things occur, including sudden deaths.
One unique thing about methadone is that everyone seems to have an opinion about it - although few have probably read the research literature on its use and outcomes. These opinions vary according to personal prejudices. Some say it is a cure for society's problems while others say it should be banned, just like heroin. People rarely have such strong opinions about penicillin, cortisone, Prozac or aspirin, each a drug with possible serious consequences, even when used 'properly'. And the clinical research regarding methadone is more comprehensive than for many other drug treatments.
Amongst the injecting population methadone prevents the spread of HIV (and probably also hepatitis C). When used in sufficient doses, it may also reduce the use of alcohol and other drugs such as cocaine. Other benefits include reduced criminality, better employment rates and enhanced home life.
Yet to some of the criticisms one would think there was some hidden scope for harm which has not been recognised by 40 years of careful research. Even Professor John Strang who chaired the authoritative UK treatment guidelines, stated that methadone treatment may have a 'sting in the tail'. Some also praise abstinence as a unique ideal and the only means to a 'pure' and 'worthy' life-style, condemning methadone maintenance as though it should never be used. Despite no supporting body of research evidence, some still support the use of naltrexone in the regular treatment of heroin addiction. Rather than clarifying matters by publishing their own findings, some issue loose statements about a particular form of treatment being 'useful' in 'well motivated' patients, without defining success, motivation or what exactly the treatment was!
In my experience most drug users, like most smokers, would dearly love to be drug-free. They nearly all regret their first drug experience. They express guilt and often go to extraordinary lengths to detoxify, including the use of unproven, dangerous and expensive means such as rapid detox under anaesthesia. Dozens of Australian addicts travelled to Israel for this procedure in the early 1990s, few with long term abstinence and some only to return to an early, unnatural death from overdose, suicide or other cause.
But abstinence is not as elusive as sometimes painted. Most smokers DO give up. Most methadone patients do eventually achieve abstinence, as shown by good research. Only a minority of them remain on continuous treatment for very long periods (>5 years). For some the abstinence is 'solid' and long lasting. For others it is temporary and fraught with problems. Deaths in such folk are tragically common and that is why treatment professionals should never push for early methadone dose reductions until the patient expresses strong commitment and readiness for such a major change in their lives. Frustration with the rigours or expense of daily treatment should not be sufficient motivation on its own for genuine 'change' . although sometimes this may be the final catalyst when other things are 'set'.
So what else do we know about methadone treatment? It is delivered in a manner which is often very unfriendly, expensive and without the supports needed by many addicted patients. Yet it still reports positive outcomes. 'Retention rates' show that people stay on it for extended periods despite these indignities. The 'down-side' of methadone treatment needs to be seen in this context. If it were always given in privacy in the community, many complaints would disappear. Yet much treatment is still given in circumstances which are very 'public'. Patients are handed doses in an open pharmacy with all-and-sundry looking on, sometimes after others have been served first. This is not ideal, nor is it consistent with the spirit of new laws on privacy. It is a mixed blessing that the price of a dose of methadone is about the same now as it was in 1988 at four to five dollars daily. Despite higher costs, increased paperwork and regulations, pharmacists to their great credit have kept prices almost inflation-free. But for this relative drop in income, they have often not been able to invest in dependency treatments specifically and move with the times. There are some notable exceptions where efforts have been made for treatment to be obtained without delay, in private, and with adequate time for professional discussion in the pharmacy or clinic involved.
Do patients need counselling? As for every other form of treatment, the more positive interventions that are included, the better the outcomes. It is known that 'bare-essentials' methadone without counselling can yield reasonable results but that added psychosocial supports improve retention and other outcome statistics. This finding is used by some, especially in the USA, to limit methadone to specialist clinics where added services can be obtained. Due to the large numbers of dependent patients and limited resources, this requirement in turn denies methadone to most addicts who nearly always outnumber clinic treatment spaces available.
Can methadone be abused? Of course it can, like almost any other drug. But excessive doses of methadone in habituated people are generally said to be rather uninteresting . and methadone is not a 'party' drug. Prescribed patients who take additional methadone can develop severe constipation. They may also sweat excessively and have poor libido. They use little if any other drugs or alcohol and are involved in little extraneous activity such as employment, crime or domestic violence. They usually learn rather quickly that taking excess methadone is not consistent with most other activities. Also, they may learn that taking the correct dose for the individual takes away all cravings and allows normal energy levels, appetites, creativity and other facets of normal human activities. Some experienced clinicians used to describe this as 'blockade' treatment and it is disappointing that none of them ever researched it.
But this is just one part of the task of clinicians to help patients come to terms with being on maintenance medication, and the right dose for their situation. It was once thought that as long as the patient has ceased using heroin that the dose is necessarily sufficient but this may not always be the case. Some still feel depressed and lack energy on a certain dose which abolishes cravings, but may still require slightly more to regain their normal functioning.
It appears that some of the main criticisms against methadone treatment are directly due to inadequate doses being prescribed. Apart from the obvious problems of continued heroin use, this also causes an immediate scope for a black market in methadone, loitering near dispensaries and even the injecting of methadone. The introduction of an alternative, buprenorphine, has also given a new effective option for those who cannot or will not take methadone for their opioid habit. Together, these drug treatments can offer a means away from illicit opiate use, and which is acceptable to a large majority of addicts.
