Methadone maintenance

Methadone maintenance treatment is the use of methadone, administered over a prolonged period of time, as treatment for someone who is addicted to opioids such as heroin, where detoxification has been unsuccessful and/or admittance to a substance abuse treatment facility requires complete abstinence.[1][2][3][4] "Methadone maintenance makes possible a first step toward social rehabilitation" because it allows addicts to avoid the uncomfortable withdrawal symptoms that result from complete abstinence.[1] Methadone maintenance can also be used for patients who suffer with severe pain problems that are resistant to other drugs.

Modality

Methadone maintenance has been used to treat opioid dependence for more than 45 years (invented in 1937).[2][4] Therapeutic dosing is contingent upon individual patient needs, and the therapeutic dosage range is generally between 20 and 200 mg. Such a dose would not be tolerated by an opioid-naive individual. The amount of oral Methadone that an addicted individual will require is dependent on the amount of illicit substance that they have previously been used to, but as a general rule 1 gram of street Heroin is roughly equivalent to 50 to 80 mg of methadone.[5] Methadone is taken either orally as DTF (Drug Tariff Formula) methadone mixture 1 mg/1ml which is supplied as a red or clear liquid, but can now also be prescribed as a mixture containing 10 mg of methadone in 1ml of liquid (green color) or methadone 20 mg in 1ml (brown color). This is often used when a person is on a large amount of methadone and is rarely permitted for consumption unsupervised, because these formulations are not as viscous as the 1 mg/1ml mixture, they are more prone to mis-use as they are easier to inject, and also due to the high risk of diverted medication causing an overdose in an individual that is not used to such a large dose. Methadone also comes in 40mg dispersible tablets called "diskettes", as well as 5 and 10 mg pills, round or "coffin" shaped. The pills are only given in hospital settings. An individual who is prescribed 200 mg would only have to ingest 20ml of 10 mg/1ml mixture, thus making it easier to take. Methadone Maintenance can also be delivered by either IV or IM injection, and ampoules come in various strengths from 10 mg up to 50 mg, this method is often used for individuals who have a "needle fixation" and who would otherwise revert to using iv heroin.[5] Methadone is widely distributed to body tissues where it is stored and then released into the plasma. This combination of storage and release keeps the patient comfortable, free from craving, and feeling stable.

With the emergence of several treatment options such as buprenorphine (Buprenorphine was approved by the Food and Drug Administration (FDA) in October 2000), and heroin treatment (The Netherlands, Switzerland & U.K.) since 1990 some professionals no longer hold with the opinion of the General Accounting Office and maintain that buprenorphine is superior.[6] This trend is being expanded in the Western U. S. in the Human Services field.

Dispensing

Methadone is an agonist of opioids. If initial doses during the beginning of treatment are too high or are concurrent with illicit opioid use, this may present an increased risk of death from overdose.[7] Methadone maintenance generally requires patients to visit the dispensing or dosing clinic daily, depending on state controlled substance laws. Most states allow methadone clinics to close on Sundays and provide take-home medication the day before. States may require or mandate drug testing in clinic drug abuse groups and/or outside Narcotics Anonymous meetings. Methadone, when administered at constant daily milligram doses, will stabilize patients and relieve withdrawal symptoms. Patients will not feel the "high" associated with drug abuse .

In the UK, most clinics will start a new patient at 35 mg and increase the dose by 5 mg or 10 mg per day until stabilization is achieve. This ensures that a new patient does not overdose due to over-prescribing: some patients will exaggerate the amount of illicit substance that they have used in order to be prescribed a larger amount of methadone, but a knowledgeable practitioner should be able to ascertain when the correct dose has been reached. It is normal for a practitioner to prescribe daily on-site consumption for the first three months before allowing take-home doses, but it is at the sole discretion of the practitioner when and if take-home doses are allowed.[5]

Travel

In the UK, patients on methadone maintenance who wish to travel overseas are subject to certain legal requirements surrounding the exportation of and importation of methadone. The prescriber must be provided with details of travel, after which the prescriber will arrange for a Home Office Export Licence to be provided. This licence is only required if the total amount being exported exceeds 500 mg. The granting of the licence does not allow for the importation of the methadone into any overseas jurisdiction. For importation, the patient should contact the Embassy of the country of destination and request permission to import methadone onto their shores, although not all countries allow the importation of controlled drugs. The licence also allows for the re-importation of any remaining methadone back into the UK. It is normal for patients travelling overseas to be prescribed methadone in a tablet form, as tablets are easier to transport. For patients who expect to be overseas for a prolonged period of time, "courtesy" arrangements should be made at a local clinic which will arrange for the prescription of the necessary medication.[5]

Controversy

Methadone maintenance is otherwise known as drug replacement therapy or ORT (opiate replacement therapy), and has been the subject of much controversy since its inception.[2][6]

In England and Wales, criminal justice drugs workers employed by the 'Drug Interventions Programme' are based in most arrest suites nationwide. Heroin and crack cocaine users are identified either by mandatory urine tests (in areas known as DIP 'intensive'), or by cell-sweeps and face-to-face discussions with arrestees (in areas known as DIP 'non-intensive' sites). Identified drug use will often trigger a referral to local drug services, whose first line response to heroin dependence is likely to involve substitute (buprenorphine or methadone) prescribing.

This line of work originated in the mid- to late-1990s, as large-scale studies identified significant levels of heroin and crack cocaine use in populations of arrestees (particularly for theft offences). In a large-scale study of drug misuse in arrested populations, Holloway and Bennett[8] identified 466 'drug misusing repeat offenders'. Of these, 80% declared an 'unmet need for treatment' (2004:33)

Contemporaneously, the National Treatment Outcomes Research Study (NTORS) found high levels of acquisitive (money-related) offending in populations of people seeking community treatment for drug problems. In one early NTORS report, Godfrey et al.[9] identified that every £1 spent on drug treatment could yield between £9.50 and £18 of savings in social costs, mostly attributable to reductions in treatment seekers' levels of offending.

These studies, along with others,[10][11][12] were taken on by Tony Blair whilst still Shadow Home Secretary, as Conservative policy regarding drug misuse was relatively undeveloped. Blair disseminated a press release in 1994 entitled Drugs: the Need for Action, claiming that drug misuse caused £20bn of acquisitive crime each year; a report dismissed by the Conservative Secretary of State for the Home Department as 'four pages of hot waffle against the Government, with three miserable paragraphs at the end' (Hansard, 10 March 1994, column 393).

After winning the UK general election of 1997, Blair's first cross-governmental drug strategy established the nationwide development of an integrated drugs / crime strategy a priority. Drugs workers were in police custody suites nationwide, and seeing 50,000 people each year, in 2001.[13] The work of these teams was then formalised in 2003, given an expanded remit (working with prisoners following release, for example) and rebadged the Drug Interventions Programme.

The founding strapline for DIP was, significantly, 'out of crime, into treatment' – reflecting the crime-reduction philosophy behind criminal justice drug treatment and ongoing methadone (or buprenorphine) maintenance at that time. In their 2010 Drug Strategy, the Conservative / Liberal Democrat coalition state their continued intention to support DIP.

See also

References
  1. Auerbach, Stuart (May 10, 1976). "Methadone Unable To End Heroin Use" (PDF). The New York Daily Press. p. 26. Retrieved 12 June 2012.
  2. Schwartz, Harvey (April 7, 1973). "County methadone clinic controversy continues" (PDF). The New York Daily Press. Retrieved 12 June 2012.
  3. Breining and 5 others (multiple contributors), Bernard G. (2005). The Addiction Professional: Manual for Counselor Competency. Orangevale, California: Breining Institute. p. 163.
  4. Joseph, PH.D., Herman; Sharon Stancliff, M.D.; John Langrod, PH.D. (October–November 2000). "Methadone Maintenance Treatment (MMT): A Review of Historical and Clinical Issues" (PDF). The Mount Sinai Journal of Medicine. 67 (5 and 6): 347. Retrieved 12 June 2012.
  5. http--www.rcgp.org.uk-PDF-drug_meth%20guidance.pdf
  6. California Alcohol and Drug Programs. "Narcotic Treatment Programs". FAQ's Re: Licensing (Online Website). CA.gov. Retrieved 17 June 2012.
  7. Sordo, Luis; Barrio, Gregorio; Bravo, Maria J.; Indave, B. Iciar; Degenhardt, Louisa; Wiessing, Lucas; Ferri, Marica; Pastor-Barriuso, Roberto (2017-04-26). "Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studies". BMJ. 357: j1550. doi:10.1136/bmj.j1550. ISSN 0959-8138. PMC 5421454. PMID 28446428.
  8. Katy Holloway; Trevor Bennett (2004). The results of the first two years of the NEW-ADAM programme (PDF). Home Office. ISBN 978-1-84473-258-6. Archived from the original (PDF) on 2009-12-07.
  9. Godfrey, Christine; Stewart, Duncan; Gossop, Michael (1 June 2004). "Economic analysis of costs and consequences of the treatment of drug misuse: 2-year outcome data from the National Treatment Outcome Research Study (NTORS)". Addiction. 99 (6): 697–707. doi:10.1111/j.1360-0443.2004.00752.x. PMID 15139868.
  10. Arun Sondhi; Joanne O'Shea; Teresa Williams (2002). Arrest referral: emerging findings from the national monitoring and evaluation programme (PDF). HR. ISBN 978-1-84082-860-3.
  11. http://www.nationalarchives.gov.uk/ero/details.aspx?seriesid=64444&deliverableUnitId=520&entrypoint=HO/421/2/P2/DPAS/CDPUR23.PDF
  12. Michael Hough (1996). Drugs misuse and the criminal justice system: a review of the literature (PDF). Home Office. ISBN 978-1-85893-440-2.
  13. "Updated Drug Strategy 2002" (PDF). 2002. Retrieved February 18, 2017.
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