Methadone Maintenance Treatment: Has It Crossed Into The New Century As A Viable Treatment Option.
fix me quick
Iím hanging out and feeling sick.
I need a remedy, you know the sort
The kind you drink, or shoot or snort.
patient, patient please
Could you please get on your knees
Pretend Iím God, let me hear your pleas
Iíll fix you up if you pay the fees.
doctor, on the phone
You promised to put me on the Ďdone
Give it to me, Iíll get a loan
The dealers have stripped me to the bone.
patient, your not fallow
Those bones of yours, they still have marrow
Please donít think that I am shallow
But I need money to fill my barrow
doctor, Iím your man
Just give me the Ďdone, Iíll piss in your pan
Iíll pay you for tests you never ran
Iíll praise the privatisation plan
patient, your so wise
Hereís your Ďdone, I sympathise
Iím paid to hear your pathetic cries
Iím the doc, with the methadone franchise
(Wally, Userís News, 1998 (28):27).
The above poem serves to illustrate the dysfunctional relationship between doctor and junkie, as written by a heroin addict attempting to withdraw from heroin. It is a common cry for sympathetic help from the heroin users of Australia, who are struggling to cope with the misery in their lives, brought about by their addiction.
During the next decade, methadone maintenance programs face new challenges and continuing hardships. How far new treatments and improvement efforts will go, toward alleviating heroin users of their addiction, remains to be seen.
Since the late 1960ís, Methadone has been the only drug available to aid heroin withdrawal in Australian heroin addicts. It has proven itself to be an effective drug and has seen many success stories (Ward, Mattick and Hall, 1992). Dozens of independent studies, conducted by critical evaluators in different countries, have agreed that maintenance with methadone is both safe and effective over periods of years when medicine is prescribed in adequate daily doses, under competent supervision (Dole, 1994). Why then are we witnessing drug trials in Australia for new pharmacotherapies to combat heroin addiction? Is it that methadone has had its day? No, not necessarily. However there is room for improvement within drug policy related to the heroin and users.
Given supply trends, and the virtual impossibility of halting the drug trade to Australia, the situation will get worse in future years, unless new strategies are found to combat the situation. There are a number of shortcomings relating to Methadone Maintenance Treatment, (MMT) which include physical aspects, dosage levels and the notion that methadone replaces one addiction with another. It is the intention of this paper to investigate further options for treatment of heroin addicts, and to assess ideas for reformulation of policies. It is necessary to provide a brief history of MMT, its positive and negative effects to the individual user and society, to highlight the current governmentís drug policies, and then to suggest methods for reformulation of policies in relation to methadone.
Background of Methadone
Methadone, a long acting synthetic narcotic analgesic, was first used in the maintenance treatment of drug addiction in the mid 1960ís by Drs Vincent Dole and Marie Nyswander of Rockefeller University. Methadone is widely employed throughout the world, and is the most effective known treatment for heroin addiction (Institute of Medicine, 1990). The goal of MMT is to reduce illegal heroin use and the crime, death and diseases associated with heroin addiction. Methadone can be used to detoxify heroin addicts, but many heroin addicts who detox using methadone or any other method sometimes return to heroin use. Therefore the goal of MMT is to reduce and even eliminate heroin use amongst addicts, by stabilising them on methadone for as long as necessary, to help them avoid returning to previous patterns of drug use.
The 1996 Premierís Drug Advisory Council Report emphasised reducing demand for heroin, encouraging treatment support and rehabilitation where possible, and concentrating law enforcement resources on curbing the supply of illicit drugs in local communities and state wide. It was stated that an appropriate balance between these aspects is essential if the harm being done to society is to be minimised. Under the report heading of "Expanded Support and Treatment", it was suggested priority should be given to developing research based clinical trials on the use of pharmacological alternatives such as LAAM, buprenorphine, naltrexone and slow release oral morphine.
The 2000 Drug Policy Expert Committee, stage one report, concludes that Victoria has significantly improved its response to the drug problem, but that the drug situation has continued to deteriorate. The drug trials proposed by the previous report are still underway with no conclusive evidence. The Governmentís current drug policy articulates the major themes of prevention, saving lives, expanding treatment and effective law enforcement. In addition to this, there appears to be an emphasis on engaging the communities help in fighting heroin addiction. This is evidenced with the injecting facilities trial where the opinions of local communities were actively sought to ascertain viability of such a strategy. Surprisingly, the report makes little mention of the drug trials currently underway around Australia. As the results of the new pharmacotherapy trials are not due until late 2000 early 2001, the focus has been more on the heroin injecting rooms being set up in Melbourne. Hopefully, if approved the injecting rooms will be a way of keeping the users off the streets, more healthy and extending their longevity.
Positive Aspects of MMT
According to Firshein (1998) heroin is one of the hardest drugs to quit "cold turkey", and for good. The MMT program aims to reduce the health, social and economic harms to individuals, their families and the community associated with illegal opiate use.
Physiological Issues of MMT
Some of the physiological effects of withdrawing from heroin on MMT include nausea, vomiting, diarrhea and cold sweats. It is a very uncomfortable process for the user, however, to withdraw totally from drugs without substitution pharmacotherapy, would result in a more uncomfortable and almost unbearable process. Physical withdrawal or detoxification from most drugs takes from four to ten days (Firshein, 1998). Many people find psychological withdrawal much harder to cope with than physical withdrawal. Going through physical withdrawal is often just the beginning of the process. Psychological and emotional issues will often surface and need to be addressed. The person is highly likely to start using again if they don't face these issues. According to Firshein (1998), MMT is a replacement therapy in which heroin addicts take regular doses of the long acting synthetic opiate methadone to quell withdrawal and cravings that would otherwise drive them back to heroin use. It is one of the most successful treatments for heroin addiction. (p.1)
Reduction in Drug Related Crime
There has long been a link between heroin addiction and acquisitive crime. Researchers have consistently found that a large proportion of the heroin dependant population engage in criminal activity (Inciardy & Chambers, 1972; Voss & Stephens, 1973, cited in Kaye, Darke, & Finlay-Jones, 1998). Bell, Mattick, Hay, Chan and Hall (1997) found that MMT actually aided in reduction of drug related crime. The study was conducted in Sydney over a 12-month period, and found that crime dropped promptly and substantially on entry to treatment to a level of acquisitive crime about 1/8th that reported during the last addiction period.
Public Health Issues
The health, social and economic effects of heroin are of great concern to the general community. The harm minimisation philosophy works to "supposedly" achieve a reduction in the harms caused by opiate addiction. Of course, it is important to reduce the harm to the individual heroin user. The effect on the families of the users is also of great concern. The community is concerned with the perceived criminal activity associated with heroin users. It is also well reported by the media the financial burden being inflicted on the community inadvertently by the drug users. It cannot be ignored that heroin addiction impacts strongly on the rest of society, and therefore programs like MMT help to reduce these negative effects. This is achieved by helping to wean as many users as possible off heroin, and to help them try to lead drug free lives (Victorian Methadone Program Guidelines for Providers, 1999).
Reduction of HIV Spread
In light of the AIDS epidemic, methadone maintenance becomes an even greater harm reduction strategy. In a prospective study from Philadelphia, the rate of HIV seroconversion was four times higher in heroin users on the street compared to patients on methadone maintenance (Metzer, Woody, & McLellan, 1993). Prevalence studies from the same time found that in New York City less than 10 percent of former heroin users who had entered methadone maintenance treatment prior to 1978 were HIV positive, while at the same time over 50 percent of street intravenous heroin addicts were positive (Des Jarlais, Friedman, Wood, & Milliken, 1992). As heroin usage and HIV prevalence increase, it is imperative that MMT remain as part of the drug policy.
Problems Associated with Dispensing of Methadone
It has been suggested that some addiction treatment workers have very poor attitudes towards heroin users. There are a number of reasons for their attitudes. Firstly, staff often have preconceived notions that abstinence is an achievable goal, and that MMT does not cure the addict. Secondly, staff believe that by issuing lower doses of methadone their heroin using charges may suffer fewer adverse effects and supposedly easier withdrawal from MMT thereby making their jobs less difficult. Finally, staff believe that smaller amounts of MMT would be diverted to the streets if doses were lower (Stine and Kosten, 1997). The patients themselves are also resistant to increase treatment doses of methadone. This is often based on street lore that claims MMT rots the bones, decreases libido and is more difficult to kick than heroin (Stine and Kosten, 1997). In a study undertaken to measure changes in attitudes amongst staff working in public MMT programs in Sydney, it was reported that staff attitudes resulted in reduced support for abstinence oriented policies (Capelhorn, Lumley, Irwig and Saunders, 1998). It was also found that staff retained negative attitudes towards drug users, and the level of knowledge about the risks and benefits of MMT was minimal. This problem with staff attitudes can severely impact on the effectiveness of MMT programs.
There are a number of physiological side effects as a result of MMT, all of which are most unpleasant from the view of the heroin user. It is well known that heroin withdrawal by MMT is a painful process and that is why many addicts resist, and are reluctant to enter the program. Common side effects include nausea, vomiting, cold sweats and tremors. These are typically short-term effects, but there are also long-term effects, which include sleep disturbances, aches and bone pain, dental problems, reduced libido and lethargy (Victorian Methadone Program Guidelines for Providers, 1999). Most of these long-term effects can actually be alleviated with variations in treatment dosage. Another even more serious side effect is the possibility of death from iatrogenic methadone toxicity. This is a condition where an addict may suffer a fatal reaction to methadone dosage. Capelhorn, (1994) performed a study based on a list of all 1994 methadone associated deaths using data on methadone patients held by the NSW, and Queensland Departments. The analysis discovered that of the 13 deaths in the first 2 weeks of maintenance treatment in NSW at least 10 were directly related to iatrogenic methadone toxicity.
MMT is Addictive
According to Herkt (1995), methadone is as addictive as heroin. He argues that methadone replaces one addiction with another. Herkt claims that methadone is administered in such an inhumane manner, so as to take control of the userís life and have them physically dependent on a methadone handout, only then to refuse a dose if the user misses even just one appointment. There is a medical basis to suggest that methadone is just as addictive as heroin and this can then lead to long term methadone "junkies" (Herkt, 1995). There have been reports of some addicts being maintained on methadone for at least 10 years, sometimes longer, even for the rest of their lives (NIDA, 1999). This represents up to a fifth of the heroin population (Bertschy, 1995). This begs the question: Is MMT a withdrawal program or a maintenance program? It appears that methadone in some cases, may not be doing what it was designed to do-help people to withdraw from a drug addiction for the rest of their lives.
Lack of Control
According to Herkt (1995), heroin addicts have little or no control over their lives once they enter a MMT program. He argues that the userís human rights such as the ability to travel, control over the individualsí time and aspects of privacy are subject to the prescriberís approval. Addicts who present for treatment often must urinate on demand for routine urine testing, and many have described this as demeaning and controlling (Users News, 1998). As stated by an anonymous user on MMT (1998), "Its all about power. A power game and believe me youíre not the master- they are. They like to prove it too, because part of the power game is punishment" (Users News, 1998:24).
The Future of Methadone
According to the latest Drug Policy Expert Committee Report (2000), the overwhelming tone of the report suggests a need for urgent revision and reformation of policies related to illicit drug use, in particular heroin. The Governmentís drug policy articulates the major themes of prevention or abstinence, saving lives, expanding treatment and effective law enforcement.
If the underlying theme of the 2000 Pennington Report is prevention this is a difficult concept to implement when considering MMT has actually maintained some heroin users on the illicit drug roundabout. The future of MMT as part of this policy should be reformed to try and reduce the length of time heroin users are maintained by methadone. MMT is exactly what it sais-a maintenance program. Whilst it has been around for many years, and has had measurable success in Australia and overseas, it has the potential to allow addicts to remain addicts, but of a different drug-methadone. This is not to say that the designers of this program have wanted to perpetuate heroin addictís misery, but it is more the nature of methadone that has made it become a long term part of many heroin users lives (Herkt, 1995).
If we are serious about the prevention part of the governments drug policy, then we need to reassess how MMT is run as a program, and look at ways of reducing the length of time an addict should be allowed to stay on the program. As suggested earlier, there have been reports of some addicts remaining on MMT for between 10-15 years (NIDA, 1999). Surely, this is not the desired effect of MMT. Isnít this as Herkt (1995) suggests, "replacing one addiction with another?"
Another issue with MMT is the negative light in which many heroin users perceive it. Wood (2000) reports that many long-term methadone maintenance clients would prefer to leave treatment altogether, but she also notes that withdrawal from MMT is notoriously difficult often resulting in relapse to heroin use or medical and psychiatric problems. Further evidence for the negative aspects of MMT can be found in comments made by former heroin user Nick Stafford (1997) who actually enjoyed the physical effects of methadone, but felt that the staff at methadone clinics had very negative attitudes towards users which did nothing for their self esteem. "There were no smiles for me. Instead I got pursed lips and unspoken disgust" (Stafford, 1997: 7). Given that these negatives are a recurring theme with many users, and this, in turn affects the success of their own treatment, we need to investigate other avenues of treatment for the heroin addicted. Whilst it is obvious that staff at these centres cannot be too sentimental, it is suggested that a positive change in attitude may heighten the optimism of heroin users who are on MMT. Perhaps an intense retraining schedule of staff, doctors and other professionals involved could create a more human touch and allow the user to be seen as a person, rather than a "worthless junkie" as represented in the opening poem.
New Pharmacotherapies and Rehabilitation
The drug trials outlined in the 1996 Premierís Drug Advisory Council Report are still underway around Australia and many professionals involved in the treatment of heroin addiction will eagerly await the results. Wood (2000) has reported preliminary findings of the first two phases of the buprenorphine trial. The results were quite favourable in that the transition from methadone to buprenorphine was quick and easy without the associated relapse back to heroin use or the wide spread need for symptomatic medication. These are the only findings so far in Australia due to the fact that the buprenorphine, LAAM, naltrexone and slow release oral morphine trials are still taking place. These new pharmacotherapies may be new to Australia but buprenorphine, LAAM, and naltrexone have been trialled overseas with positive results and have been registered for some time as treatment for heroin dependence (Casadonte, 1998 & Reisinger, 1997).
These new pharmacotherapies could open up the way for greater success with a high proportion of heroin users in terms of helping them to withdraw from their addiction. Methadone has been the main method of heroin withdrawal though it has had its shortcomings, especially in that it does not suit every individual. This, of course, has led to some successes and some failures in terms of withdrawal. However, if these new drugs are successfully trialled, then there may be new hope for the heroin-addicted population. It is suggested that the appropriate drug treatment be matched to the appropriate individual taking into account his physiological, psychological and social needs. A solution is to make the heroin withdrawal experience more tailored to the individual and more "pleasant". This may be possible with buprenorphine, LAAM , slow release oral morphine or naltrexone. According to McQueen (1998), it is normal medicine to acknowledge personal needs, tastes and the inherent human dislike of feeling dependent on or controlled by others. Only in this way can heroin users hope to gain more autonomy, and have a renewed positive attitude to pharmacotherapeutic treatments for their addiction.
It is important to understand the heroin user within a broader social context. The aim of any drug withdrawal program should be, not merely helping the addict to abstain from drugs, but helping them assimilate back into society as individuals with worthwhile skills to offer the community. This obviously includes helping them find employment, accommodation and most importantly being capable of stable functional relationships. This may occur as part of the heroin injecting rooms experiment, where it is proposed that users will not only be offered a safe, clean place where they can inject heroin, but also a network of support services, including doctors, nurses and counsellors who are available to assess each userís health and mental condition. When appropriate, these professionals can recommend necessary treatment options to aid in their eventual recovery and possible integration back into society.
Similarly, MMT should be focussing on long-term rehabilitation of the individual. If the user is placed on the appropriate drug that best suits his needs, then this could be step one of the rehabilitation process. The next step would be to ensure, through constant monitoring, that the user is making progress in withdrawing from heroin within a minimum time frame. Once the withdrawal process is completed, then an assessment should be made of the individualís social and emotional condition. The aim would be to integrate the user back into society. If skills or retraining are needed prior to searching for employment, then this service should be provided. The establishment of a drug rehabilitation shelter, as temporary accommodation for those users who are part of a drug withdrawal program, should be considered. An assessment should also be made of the individualís level of self-esteem, and if needed, attendance at a self-development course should be arranged. This holistic approach to drug rehabilitation includes not only the initial medical treatment, but also combines the essential components required in order to gain a greater chance of usersí rebuilding their lives.
The governmentís drug policy of harm reduction has been designed, implemented, and enforced with virtually no input from the Australians they affect most: drug users. Drug abuse is a serious problem both for individual citizens and society at large, but the so-called war on drugs through harm reduction has made matters worse, not better. The reformation of policies relating to methadone should concentrate on minimising the drug withdrawal time span. It is important to see methadone as only one part of the pharmacotherapeutic program aimed at heroin withdrawal. The aims should not be to prolong withdrawal with traditional "methadone maintenance," but to ensure each individual presenting for treatment is monitored closely and is administered the most appropriate drug, which will see their recovery process shortened and more successful. The suggestions made for a holistic approach to rehabilitation, include taking into consideration the users physical state, as well as their emotional and social wellbeing. It is important to consider the fundamentals such as adequate shelter and their basic human need to be accepted as decent human beings who are capable of living worthwhile lives.
Despite the irony concerning MMT and the government drug policy of abstinence, MMT is still the most successful treatment option for heroin withdrawal in Australia (Ritter, Bammer, Lintzeris & Kutin, 1997). However, methadone is not suited to every heroin dependent individual. Some cannot tolerate its side effects and many fear the prolonged withdrawal effects. Many clients find having to present daily for their dosage very restrictive. Finally the cost of the program is prohibitive (Stafford, 1997). In addition, the rules and restrictions of MMT, the lack of autonomy over treatment, and the attitudes of those who treat, also deter many clients from entering MMT.
There is obviously a need for treatment drugs which can be matched to the individual. If there were a greater array of options, then the medical practitioner would be able to choose the most suitable drug based on how successfully the client coped with the methadone dosage. Also, with these new drugs being trialled they may be more effective and faster acting, thereby helping to reduce the length of the withdrawal period. This is important because if the drug policy aim is for abstinence rather than maintenance, then reduced withdrawal time may be more likely to occur if a client is on a program with one of the new pharmacotherapies.
It would be easy to believe that these new pharmacotherapies will be the wonder drugs to help Australiaís heroin users. This could be a naïve stance, considering that even with the broadening of pharmacotherapy options, there will always be a drug-using population. However, the problem may still occur that these new drugs will not be suitable for all users, but at least clinicians will have more options available to offer users. This will hopefully result in reduced time within a heroin withdrawal program. Positive attitude changes would be helpful on behalf of methadone providers as well as users, to create a functional environment rather than as "us" versus "you" situation. As stated by Ritter et al these drugs "Öwill not be the perfectly fitting keys. But what they maybe for some clients is a better fitting key that will more easily open the door to change."
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Written By Tammy Cohen