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AmyHakanson ProfessorDavidova LifeUnlimited? June12,2013 TheEffectivenessofMethadoneMaintenanceTreatmentPrograms Humansrelyonconsumptiontosurvivetheingestionoffoodisoneofthemostbasic humaninstincts.Alongwithfood,humanshavealonghistoryofconsumingmindaltering substances,includingnaturalherbsfoundinnatureandfermenteddrinkscontainingalcohol. However,inthelastfewcenturies,humantechnologyhasadvancedtoalevelthatharsher,more addictivesubstancescanbecreatedandconsumed,includingnarcoticsandamphetamines.Drugs likethesepresentveryserioussocietalproblems,creatingtheirownmicroeconomyofillegal supplyanddemand,inadditiontophysicallyandmentallydamagingthosewhobecomeaddicts. Asaresult,manymethodsofaddictiontreatmenthavebeencreated,oneofthemostnotablebeing methadonetreatment.Methadoneisitselfamanmade,moodalteringopioid,andposesmanyof thesamesocietalproblemsastheoriginalnarcotics.Thispaperwillexplorethehistory,progress, benefitsandconsequencesofmethadonetreatmentforopioidaddiction. Itshouldbenotedthataddictionisnotsynonymoustodependance.TheNationalInstitute onDrugAbuseillustratesthisdistinction: Physicaldependenceoccursbecauseofnormaladaptationsto chronicexposuretoadrugandisnotthesameasaddiction. Addiction,whichcanincludephysicaldependence,isdistinguished bycompulsivedrugseekingandusedespitesometimesdevastating consequences.(PrescriptionDrugs)

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Opioidsarefrequentlyprescribedforpain,andalthoughpatientsmightnotdevelopan addictiontothemedication,theycanveryeasilybecomephysicallydependent.Thosedependent onopiatesrequiremethadoneoranalternativereplacementtoavoidwithdrawalsjustasaddictsdo theymaynothaveasmanyoutsidebarrierstosobriety(theirenvironmentmaybequitestable,they mayhaveadisposableincomeandinsurance,etc),sotheirchancesofrecoveryareusuallygreater thanthoseofaddicts.Thewidelyheldbeliefthatmethadoneclinicsareforthehomeless, prostitutesandthementallyilldoesnotaccuratelyrepresentthefullpopulationwhichinreality requiresmethadone.Forthepurposesofthispaper,whichfocusesnotontheclientsofmethadone clinicsbutonthesynthesizeddrugitselfandtheaffectsithasonpeopleandonsociety,addiction willbeusedastheframeworkforexploringtheeffectivenessofmethadone.Whilethosewhoare dependenton(butnotaddictedto)opiatesarenotlessentitledtorecovery,theydonotpresentan immediatedangertosociety.Addictionisadiseasethatcanleadtophysicalandsexualabuse, prostitution,homelessness,crime,mentalillness,incarcerationanddeath.Assuch,moreattention willbegiventotheexplorationofmethadoneasatoolforaddictionrecovery,andnotsimplya methodtoeradicatephysicallydependenceonopiates.

AccordingtotheAmericanSocietyofAddictionMedicine,addictionis

aprimary,chronicdiseaseofbrainreward,motivation,memoryand relatedcircuitry...Addictionischaracterizedbyinabilityto consistentlyabstain,impairmentinbehavioralcontrol,craving, diminishedrecognitionofsignificantproblemswithonesbehaviors andinterpersonalrelationships,andadysfunctionalemotional response.Withouttreatmentorengagementinrecoveryactivities,

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addictionisprogressiveandcanresultindisabilityorpremature death."(DefinitionofAddiction)

Addictionisnotasimpledisease.Itisnotcontractednotinthewayonemightcontract thefluvirusfromairbornepathogens.Addictionisbuiltupovertimewiththeabuseoflegalor illegaladdictivesubstances.Therearemanydifferentsubstancesandbehaviorswhichcancause addiction.Thispaperwillfocusonopioidaddictioncausedbyillegalopiates(heroin)orprescribed opiates(oxycodone,morphine).Inmostcasesofopioidaddiction,toleranceanddependenceare builtupbeforethereisatransitiontoaddiction.Essentially,thismeansthatwithrepeatedopioid use,thebrainoftheuserisalteredsothatwhentheopioidsarepresent,thebrainfunctions normally,andwhentheopioidsareabsent,thebrainfunctionsabnormally.(Kosten,14)When opioidsenterthebloodstream,theybondwithspecializedproteinscalledmuopioidreceptors. Locatedonbraincells,theseopiatesensitiveneurons,whenattachedtoopioidchemicals,produce thesamebrainprocesseswhichproducefeelingsofpleasurewhenoneengagesinactivitiesthat promotebasiclifefunctions,suchaseatingandsex.(Kosten,14)Perceptionofpainisalso reducedwhenopioidsattachedtothesereceptors,whichiswhyopioidshavelongbeenprescribed forpainrelief.However,whenopioidsareusedintheabsenceofpain,thepleasurablefeelings triggeredbytheopioidreceptorsmayencouragefurtheruseofthedrugforrecreation.Oneofthe mainbraincircuitsaffectedbyopiatesisthemesolimbicrewardsystem,whichgeneratessignals inapartofthebraincalledtheventraltegmentalareathatresultinthereleaseofdopaminein anotherpartofthebrain,thenucleusaccumbens.Thisreleaseofdopamineintothenucleus accumbenscausesfeelingsofpleasure.(Kosten,14)

Withrepeatedexposuretoopioids,atoleranceisbuiltupinthemuopioidreceptorsinthe

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brain.Thismeansthatmoredrugsareneededtoproducethesameresultsachievedatthe beginningofdruguse.Tolerance,alongwithdependence,bothleadtothecompulsivedruguse andcravingthatdefineaddiction.Asaforementioned,dependenceisanadaptationtofrequentand regulardruguse,suchthatthebodyoftheuserwillundergowithdrawalsifthedruguseisabruptly stopped.Thesewithdrawalsymptomsariseprimarilyfromanotherbrainsystemcalledthelocus ceruleus.Neuronsinthelocusceruleusproducenoradrenaline,whichstimulateswakefulness, breathing,bloodpressure,andgeneralalertness.(Kosten,15)Whenopioidsattachtomuopioid receptorsinthelocusceruleus,noradrenalineproductionisreduced,leadingtodrowsiness, slowedrespiration,lowbloodpressure...(Kosten,15)Asopioiduseisrepeated,thelocus ceruleusneuronsaccommodatebyincreasingactivity,eventuallyproducingnormallevelsof noradrenalinewhenusersareundertheinfluenceofopiates.Thismeansthatwhenusersarenot undertheinfluenceofdrugs,levelsofnoradrenalineareexcessivelyhigh,causingjitters,muscle cramps,diarrheaandanxiety.Thesearesymptomsofwithdrawal.

OpioidaddictionintheUnitedStatesfirstbecameamajorproblemduringandafterthe CivilWar,whenopioidswerefrequentlyprescribedforpain.Intheearlypartofthe19thcentury, themajorityofopiateaddictsweremiddleorupperclasswomen,whowereprescribedthe medicationforrelieffrommenstrualandmenopausaldiscomfort.CivilWarveteranscomprised anotherdemographicofopiateaddictsduringthisperiod,theiraddictionsresultingfromprevious medicalprocedures.Thisformofopiateaddictionisclassifiedasiatrogenic,meaningcausedbya doctorormedicaltreatment.Thosesufferingfromiatrogenicopiateaddictionwere,atthetime, treatedsympatheticallydoctorsoftenprescribedmoreopiatesasacure,andeventually sanitariumswereestablishedfortreatment.Astimeprogressed,thedemographicofopiateaddicts changeddrastically.Heroinwasintroducedin1898,originallyasacoughsuppressant.This,

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combinedwithhypodermicinjectionmethods,changedthenatureofopioidaddictionforever.By theearly20thcentury,mostopiateabuserswereyoungmenintheir20s,andthesympathythat hadbeenhistoricallyshowntowardsCivilWarveteransandwomenwaseventuallyreplacedwith thebeginningsofthestigmaoftenshowntowardaddictstoday.Manymoreaddictsobtainedtheir drugsillegally,andtherewasanincreaseindrugrelatedcriminalactivity.(MedicationAssisted Treatment,12) Methadonewasfirstexploredasasubstituteforheroinandotherillegalopiatesin1962, whenDr.VincentP.DolebecamechairoftheNarcoticsCommitteeoftheHealthResearch CouncilofNewYorkCity(MedicationAssistedTreatment,17).Otheropiateshadpreviously beenusedformaintenance,butwereeliminatedduetotheirshorthalflives,whichwouldrequire multipleinjectionsperdayinordertomaintainapatient.Thebenefitsofmethadoneasfoundinthe studyconductedbyDolewereasfollows: Patientsdidnotexperienceeuphoric,tranquilizing,oranalgesic effects...theycouldsocializeandworknormally... Atherapeutic,appropriatedoseofmethadonereducedorblocked theeuphoricandtranquilizingeffectsofallopioiddrugsexamined. Nochangeusuallyoccurredintolerancelevelsformethadoneover time...therefore,adosecouldbeheldconstantforextendedperiods. Methadonewaseffectivewhenadministeredorally...patientscould takeitonceadaywithoutusingasyringe. Methadonerelievedtheopioidcravingorhungerthatpatientswith addictiondescribedasamajorfactorinrelapseandcontinuedillegal use. Methadone,likemostopioidclassdrugs,causedwhatwere

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consideredminimalsideeffects,andresearchindicatedthat methadonewasmedicallysafeandnontoxic.(MedicationAssisted Treatment,1718) Inshort,Dolefoundthatmethadonedoesnotinducethecommonimmediatesideeffectsof heroin,andinfactblockstheeffectsofheroinwhenabusedmethadoneusersdidnotbecome tolerantofthedrug,meaningthatthedailydoserequiredwouldnevergoupbecauseitis administeredorally,methadoneiseffectiveasadailydose(ascomparedtothemultipledosesof heroinrequiredbyaddicts)methadoneeffectivelyrelievesthecravinginvolvedwithopioid withdrawalandmethadone,aswellasmostotheropioids,isfairlynontoxic. (MedicationAssistedTreatment,18) Alloftheaboveinformationseemstoindicatethatmethadoneisaneffective,longlasting solutionforopioidaddiction.However,usingmethadoneasareplacementforillicitstreetdrugs isnotstraightforwardintheleasttheenvironment,resources,stimuliandpsychiatrichealthofdrug addictsareessentialfactorsinrecovery.Addictionisfirstandforemostadiseaseofthebrain. Withouttreatingthecauseofthediseasethereisnohopeforrecovery.InherbookMethadone: BadBoyofDrugTreatment,RebeccaJanesexploreswhatdoesanddoesntworkincurrent methadonemaintenanceprograms.Janeselaboratesonseveralbarrierstorecovery,thefirstbeing theincorrectbeliefsheldbythegeneralpublic.Allofthesemistakenbeliefsarisefromthe stigmatizationofmethadoneclientsthemselves.AstigmaisdefinedbyErvingGoffmanasbeing anattributethatmakes[one]differentfromothersinthecategoryofpersonsavailablefor[one]to be,andofalessdesirablekind...[one]isthusreduced...fromawholeandusualpersontoatainted, discountedone.(Goffman,3)Theattributethatstigmatizesmostmethadoneclinicpatientsistheir addictiontheoutsideworldchoosestoreducethesepeopletooneoftheirglaringdefects.Instead ofbeingviewedthemasordinarypeoplewhohappentohavedevelopedadisease,addictsare

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believedtobeweakwilledandinferior.Theiruseofmethadoneasanagenttohaltwithdrawals andtoreplaceillegalstreetdrugsisseennotasatoolforrecovery,butasagovernmentfunded methodtogettheirfix.Janesexplainstherealityofthesituationthatthedoselevelof methadoneasprescribedtoanaddictisadjustedtoatherapeuticlevel.Asexplainedabove, opiatesfundamentallychangethechemicalfunctionsofthebrain.Itisnotrealistictoexpecta seasoneddrugaddicttosimplystopcoldturkey.Theirbrainwillproducefarmorenoradrenaline thanisneeded,causingverydifficultwithdrawalsymptomsthatalmostalways,withoutastable environmentandpsychiatrichelp,leadtorelapse.Thefirstpriorityforanaddictenteringinto recoveryisareturntophysicalnormalcythisiswheremethadonelevelscomeintoplay.The dosageofmethadoneprescribedmustbehighenoughsothatthemuopioidreceptorsarereceiving enoughmethadonetosuppresswithdrawals,butnottoinducethelethargyofgettinghigh. Ideally,oncetheaddictismaintainedonanappropriatedoseofmethadone,heorshewillbegin theprocessoftaperingoffthemethadoneitself,whichcantakeanywherefromsixmonthstothree years.Insomecases,patientsnevertaperofffully,andcontinuetobemaintainedonmethadone forlife. Thisraisesanothersideofthestigmatizationofmethadoneclientstheviewpointheldby manyrecoveredaddictsthatmethadoneitselfisadrug,andunlesscannotbecompletelyclean withoutabsoluteabstinence.Otherrecoveryprograms,namelytheAnonymousprograms,promote totalabstinencefromdrugsandalcohol.TheAnonymousprograms,includingAlcoholics Anonymous(AA),NarcoticsAnonymous(NA),CodependentsAnonymous(CoDa),AlAnon andothersarefamiliarinstitutionstomostofthegeneralpopulation.AAwasfoundedin1935 NA,whichisbaseduponAA,wasofficiallyfoundedin1953.Bothprogramsare12stepbased,a methodofrecoverythatwasintroducedintheAAprogram.Thetwelvestepsareasfollows: 1.Weadmittedthatwewerepowerlessoverouraddiction,

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thatourliveshadbecomeunmanageable. 2.WecametobelievethataPowergreaterthanourselves couldrestoreustosanity. 3.Wemadeadecisiontoturnourwillandourlivesover tothecareofGodasweunderstoodHim. 4.Wemadeasearchingandfearlessmoralinventoryofourselves. 5.WeadmittedtoGod,toourselves,andtoanother humanbeingtheexactnatureofourwrongs. 6.WewereentirelyreadytohaveGodremoveallthese defectsofcharacter. 7.WehumblyaskedHimtoremoveourshortcomings. 8.Wemadealistofallpersonswehadharmed, andbecamewillingtomakeamendstothemall. 9.Wemadedirectamendstosuchpeoplewhereverpossible, exceptwhentodosowouldinjurethemorothers. 10.Wecontinuedtotakepersonalinventoryandwhenwe werewrongpromptlyadmittedit. 11.Wesoughtthroughprayerandmeditationtoimproveour consciouscontactwithGodasweunderstoodHim, prayingonlyforknowledgeofHiswillforusandthe powertocarrythatout. 12.Havinghadaspiritualawakeningasaresultofthese steps,wetriedtocarrythismessagetoaddicts,andto practicetheseprinciplesinallouraffairs.(NarcoticsAnonymous,

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17) NAstwelvestepsdonotgiveadescriptionofhowtophysicallystopusing.Althoughthe 3rdtraditionofNAstatesthattheonlyrequirementformembershipisadesiretostopusing, (NarcoticsAnonymous,60)theliteratureitselfisnotdesignedtobetheonlytoolrequiredfor recovery.ArguablythemostimportantfacetofNAisthegroupaspectthemeetingsinwhich addictsgathertodiscusstheircommondisease.Inthesemeetings,addictsareencouragedtouse completehonestyregardingtheirpastdruguseandtheircurrentdruguseorabstinence.Members celebratebirthdaysinsobrietylengthsoftimetheyhavespentsober.TheNAandAA programshavebeenproventoworkforoveramillionpeoplethroughouttheirexistencehowever, whenitcomestothosewithseriousopioidaddiction,sometimesthe12stepsandmeetingsarenot enough.TheNAprogramstipulatesthatyes,theonlyrequirementformembershipisadesireto stopusingbutthetermusingincludestheuseofmethadonetomaintainalevelofphysical relieffromwithdrawals.Therefore,methadoneclientsarenottechnicallysober.Theyarenoteven necessarilytryingtogetsobernotinthesensethatNApromotes.Althoughtheidealuseof methadoneisasatooltoslowlytaperoffdrugsuntilonecaneventuallystopusingeventhetool altogether,manypatientsfindthattheyareneverfullyabletohalttheirmethadoneuse.Their bodiessimplywillnotadjusttoalifewithoutsomeformofopioid,andsotheymustbemaintained onmethadoneindefinitely.Thisraisesaninterestingdilemma.Addictsonmethadonemaintenance arestillinneedofthestructureofagrouprecoveryprogram.AsstatedinBulletin#29ofNA RegardingMethadoneandOtherDrugReplacementPrograms, [NA]membersondrugreplacementprogramssuchasmethadone areencouragedtoattendNAmeetings...Whilesomegroupschoose toallowsuchmemberstoshare,itisalsoacommonpracticeforNA groupstoencouragethesemembers(oranyotheraddictwhoisstill

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using),toparticipateonlybylisteningandbytalkingwithmembers afterthemeetingorduringthebreak.Thisisnotmeanttoalienateor embarrassthisismeantonlytopreserveanatmosphereofrecovery inourmeetings.(Bulletin#29) Althoughthesentimentexpressedabovedoesnotseemtocontainnegativeconnotations concerningmethadoneclients,therealityisthatindividualmembersofNAmaynotcomplywith thisacceptanceofmethadoneusers.AsJanesillustrates,hostilityoftenovertakescompassionin therecoverycommunity...Inmanyrecoveryprograms,particularlyAAandNA,themethadone clientisshamedasnotclean.(Janes,35)Thetruthofthematteristhatcleanlinessisoften relative.ShouldNAmemberswithdebilitatingpsychiatricillnesses(separatefromtheirdiseaseof addiction)refrainfrommoodalteringmedication?Forexample,ifanaddicthasmajordepressive disorder,shouldthataddictabstainfromantidepressantssimplybecausetheyareaformofdrug? ThisisacommonquandaryintheAnonymousprograms.Themajorityofmemberstendtoagree thatprescribedmedication(fromadoctorthatisfullyawareofthepresentdiseaseofaddiction)is appropriateandevennecessaryforrecovery.Ifsomeonehadastaphinfection,thatpersonshould receiveantibiotics.Failuretodosocouldresultinfatality.Depressionandothermentaldisorders needtobetreated,ortheywillcausemajorproblems.So,ifitisacceptedtouseantidepressants andspeakinNAmeetings,whyshouldmethadoneclientsbeostracized?Theyarenotusingany illegaldrugs,andtheyarenotevennecessarilyintoxicatedtheyarebeingmaintainedona prescribeddoseofmedicationsothattheycanlivetheirlivesnormally.Itisconsistentlydifficult toseewherethehypotheticallineisdrawnwithregardstosubstancesinNAorotherAnonymous programs.Thegoalofsuchprogramsistodiscontinueuseofaddictivesubstances,yetcoffeeis serveduniversallyateverymeeting.Caffeineisastimulantthatcanleadtotoleranceand dependence,justlikeopioidsandalcohol,andyettheconsumptionofitisencouragedinrecovery

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groups.Manyrecoveredaddictsandalcoholicsalsosmokecigarettes,whichhavebeenprovento bebothextremelyaddictiveanddeadly(withprolongeduse). Myopiniononmethadonemaintenanceisindefinite.Thesituationisnotblackand whitethereisnotonesolutionthatworkstotallyeffectively.Myviewsonaddictionarecolored bythefactthatIamanalcoholicmuchoftheinformationprovidedaboutNAandtheAnonymous programsisnotfromresearch,butfrommyownexperience.Ihaveoftencomeintocontactwith addicts,andhavetalkedatlengthaboutthemeaningofsobriety,thedefinitionofabstinence.My thoughtsonmethadoneareasfollows:Ibelievethatmethadonecanbeanextremelyeffectivetool foraddictionrecovery.However,sinceaddictionisnotapurelyphysicaldisease(infact,itisfirst andforemostadiseaseofthebrain)onemedicationanymedicationalonecannotcure addiction.Mostofwhatbarsaddictsfromrecoveryisnotevennecessarilythephysicalwithdrawal symptoms.Asillustratedearlier,addicts,throughtheabuseofdrugs,associateenvironments, people,andsituationswithdruguse.Beingputintothesesituationsorconfrontingthesepeople cantriggercravingsfortheaddict,makingthemextremelyvulnerabletorelapse.Thesecravings canoccuryearsaftertheaddicthasstoppedexperiencingwithdrawalscravingshappenevenif someonewhowaspreviously(andsuccessfully)maintainedonmethadoneuntiltheywereableto taperoffcompletely.Addictionisnotadiseasethatcanbecured.Itissimilartoanallergymany alcoholicsdescribethemselvesasbeingallergictoalcohol.Ifapersonisallergictopollen,they willneedtotakeanantihistamineeverytimetheycomeintocontactwithpollinatingflowers,or theywillhaveanallergicreaction.Thesameistrueofaddicts.Preventativemeasuresareneededto keepthemfromrelapsing.InthejargonofAAandNA,thisiscalledworkingonesprogram. Methadoneclientsneedtohavetheirownprogram.Iftheyarenotcomfortablebeingapassive memberofNA,theyneedtohaveanothersourceofspiritualandpsychiatricsupport.ThisiswhyI believethatifmethadoneclinicsaregoingtobeeffective,theyneedtohaveacompetentmental

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healthstaffwhichcanofferpsychiatrichelptomethadoneclients.Anongoingprogramofsupport isneededevenaftermethadoneclientssuccessfullytaperoffthedrug.Thisprogramisneededfor theremainderoftheaddictslife,becauseaddictionisalifelongchronicdisease. Inadditiontothesenecessaryaspectsofthemethadoneclinicsthemselves,Ifirmlybelieve thatmethadoneclientscannotbeexpectedtobesuccessfulinrecoveryunlesstheyhavesupportin otherbasicaspectsoftheirlives.Manydrugaddictsarehomeless.Ifanaddictisexpectedto achievesobriety,theycannotcontinuetoliveintheveryenvironmentthatpromotestheir addiction.Therefore,inorderformethadonetreatmenttobeeffective,increasedsupportofthe homelesscommunitiesisrequired.Bethisprivatelyorgovernmentfunded,itisneeded.Further actionconcerningthepossessionanddistributionofillegaldrugsisneeded,aswell.Idonothave aneasysolutiontothisproblem.Idonotbelievethatlegalizationwouldsolvetheissue,Ithinkit wouldmerelyincreasethediversityofaddicts.Ifopioidsandnarcoticsarewidelyavailableand legalforconsumption,weasasocietywillsimplybeencouragedtoconsumethem.The prevalenceofalcoholismhasproventhis.Humansareaddictivecreaturesthatrelyonconsumption forsurvivalhowever,wedidnotevolvetoconsumesuchdangeroussynthesizedchemicals. Therefore,wemustcontinuetoworkonwaystograpplewiththeproblemswehavepresented ourselves.Methadonecanbeaneffectivetoolinthisstruggle,whenusedinasupportiveand nurturingenvironment.

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WorksCited

Bulletin#29,NarcoticsAnonymous.2012.Web.13Jun,2013. CenterforSubstanceAbuseTreatment.MedicationAssistedTreatmentforOpioidAddictionin OpioidTreatmentPrograms.TreatmentImprovementProtocol(TIP)Series43.HHS PublicationNo.(SMA)124214.Rockville,MD:SubstanceAbuseandMentalHealth ServicesAdministration,2005.Print. "DefinitionofAddiction."AmericanSocietyofAddictiveMedicine.19Apr,2011.Web.1Jun. 2013. Fraser,Suzanne,andValentine,Kylie.SubstanceandSubstitution:MethadoneSubjectsinLiberal Societies.Basingstoke:PalgraveMacmillan,2008.Print. Hofmann,FrederickG.,Winger,GailandWoods,JamesH.AHandbookonDrugandAlcohol Abuse.NewYork:OxfordUniversityPress,Inc,2004.Print. Janes,Rebecca.Methadone:BadBoyofDrugTreatment.Denver:OutskirtsPress,Inc,2010. Print. Kosten,ThomasR.andGeorge,TonyP.TheNeurobiologyofOpioidDependence:Implications forTreatment.SciPractPerspect.2002July1(1):1320 Liberto,LindsayA.,Fornili,KatherineS.:ManagingPaininOpioidDependentPatientsin GeneralHospitalSettings.MEDSURGNursing201322:1. NarcoticsAnonymousWorldServices,Inc.NarcoticsAnonymous.Chatsworth:Narcotics AnonymousWorldServices,Inc,2008.Print. "PrescriptionDrugs:AbuseandAddiction."NationalInstituteonDrugAbuse.Oct,2011.Web.1 Jun,2013.