Methadone Maintenance Therapy

What is methadone maintenance treatment?

Methadone maintenance treatment (MMT) is a comprehensive treatment program that involves the long-term prescribing of methadone as an alternative to the opioid on which the client was dependent.

Methadone
Methadone is a long-acting opioid agonist Only the treatment of opioid dependence.

Questions & Issues

How important is methadone in treating heroin addiction? What is the rationale? How do we decide when/if it can be discontinued? What is included in the psychosocial component of treatment?

Once the client is stabilized at the right dose, methadone will: suppress opioid withdrawal symptoms reduce cravings for opioids not induce intoxication (e.g., sedation or euphoria) reduce the euphoric effects of other opioids, such as heroin.

OPIOID MAINTENANCE THERAPY

The Addiction Process: Barriers to Understanding

INFLUENCE OF THE STIGMA: difficulty understanding the complexity of the disorder treatment is denied treatment is diminished treatment is discouraged treatment is conditional

I Dont Believe in Methadone

Methadone is a medication, not a religion

J. Thomas Payte, MD Founding Chair, Methadone Treatment Committee, ASAM

Overview: Opioid Maintenance Therapy

Methadone (MMT) & levoacetylmethadol (LAAM), buprenorphine (soon) most highly regulated history rationale for replacement therapy political influences diversion

OMT, Continued
Strong empirical support for safety and efficacy (30 years of data) valuable tool in reducing spread of HIV makes the pt accessible to interventions for other problems hidden populations of heroin users medical maintenance and office-based practice

What is Abstinence?

Medication is compatible with 12-step participation if appropriately prescribed by physician knowledgeable about addiction Pt on methadone is abstinent if not using illicit drugs and using legal ones as prescribed Its just another medication. Meds are a tool, not a solution

Dole: Receptor System Dysfunction

Endogenous ligand-narcotic receptor system is defective; hence high relapse rate Stabilize blood level at 150-600 ng/mL This normalizes neurological and endocrine functioning This treatment is corrective but not curative Future research: identify the specific defect and repair it
(Dole, JAMA 1988)

Genetic Factors
Recent studies show distinct genetic vulnerability to heroin and other opiates:

heroin had larger genetic influences unique to itself than marijuana, sedatives, stimulants, psychedelics (Tsuang et all; Merikangas et al; ARCHIVES 1998) Alcoholism and drug disorders appear to be independent Genetic factors impact the transition from drug use to abuse/dependence, not use itself

Diversion of Medication
political hot button key issue in formulating original regs IOM report: cannot document significant public health or safety problem confusion about DAWN data difficulty of determining cause of death

(Rettig 1995)

Reasons for Diversion

selling take-homes to buy illicit drugs need to supplement income share with or sell to addicted friend/mate unwilling or unable to enter treatment low dose policies of some programs

IOM conclusion: risks of diverted methadone do not outweigh benefits of making MMT more available
(Rettig 1995)

PHARMACOTHERAPY

Methadone vs Heroin

Can be taken by mouth Slow onset of action No continuing increase in tolerance levels after optimal dose is reached; relatively constant dose over time Pt on stable dose rarely experiences euphoric or sedating effects; is able to perceive pain and have emotional reactions; can perform; can perform daily tasks normally and safely

Methadone vs Heroin (2)

Long acting; prevents withdrawal for 2436 hours (4x-6x as long as heroin), permitting once-a day-dosing At sufficient dosage, blocks euphoric effect of normal street doses of heroin Medically safe when used on long-term basis (10 years or more)

(Physicians Guide: Opioid Agonist Medical Maintenance Treatment; CSAT 2000)

Heroin Simulated 24 Hr. Dose/Response

With established heroin tolerance/dependence

Dose Response

Loaded High
Abnormal Normality

Normal Range Comfort Zone

Subjective w/d

Sick Objective w/d 24 hrs.

0 hrs.

Time

Opioid Agonist Treatment of Addiction - Payte - 1998

GOALS FOR PHARMACOTHERAPY

Prevention or reduction of withdrawal symptoms Prevention or reduction of drug craving Prevention of relapse to use of addictive drug Restoration to or toward normalcy of any
physiological function disrupted by drug abuse

Source: MJ Kreek, Rationale for Maintenance Pharmacotherapy of Opiate Dependence, 1992

Opioid Agonist Treatment of Addiction - Payte - 1998

PROFILE FOR POTENTIAL PSYCHOTHERAPEUTIC AGENT

Effective after oral administration Long biological half-life (>24 hours) Minimal side effects during chronic
administration

Safe, no true toxic or serious adverse effects Efficacious for a substantial % of persons with
the disorder (> 15-20%)

Methadone Simulated 24 Hr. Dose/Response At steady-state in tolerant patient Loaded High

Abnormal Normality

Dose Response

Normal Range Comfort Zone Subjective w/d

Sick Objective w/d 24 hrs.

0 hrs.

Time

Not Holding Strategies

Cognitive,

Behavioral Interventions Increased contact, counseling, therapy Alter urinary pH? Is patient fixing? - Raise dose Split Dose?

Rapid Metabolizer - High Single and Split Dose Simulation

700 600 Single

High
500

High Single Split Dose Minimum

ng / ml

400 300 200

Normal

Sick
100 0 0 4 8 12 16 20 24 'Normal' Ceiling

Hours

TAPERING
how many remain abstinent? tapering readiness tapering strategies clonidine handling relapse

Buprenorphine (1)
1970s - partial opioid agonist useful in opioid dependence treatment 1990s - clinical trials long duration of action; smooth onset low physical dependence mild withdrawal syndrome good name on the street

Buprenorphine (2)
DATA 2000 permitted use in MD office FDA approved Subutex and Suboxone in 2002 Physicians must meet training requirements: certified in addiction medicine, participated in clinical trials, or took 8 hour course by specified organizations

Buprenorphine (3)
SUBUTEX & SUBOXONE Sublingual tablets Suboxone has naloxone added to discourage needle use Partial agonist: ceiling effect Expensive: $300/month at average dose Not interchangeable with methadone

Buprenorphine (4)
Poor oral bioavailability Sublingual administration requires longer observation Abuse documented in Europe, Australia, and New Zealand How much training should be required for physicians to use it?

Naltrexone
antagonist; how it works who does it work for? accelerated withdrawal protocols Doles critique utility with alcoholics

Methadone in Pregnancy

Comprehensive MMT treatment with prenatal care improves neonatal outcome Withdrawal is rarely appropriate during pregnancy Methadone is not teratogenic; children have been followed into adulthood Appropriate dosing is very important Breast feeding OK if no other drug use

Opioids and Chronic Pain

Opioid tolerance & physical dependence DO NOT equal opioid addiction

Loss of Control Indices:
Continued use despite adverse consequences Illicit or inappropriate drug seeking behavior
In response to craving or drug hunger In the absence of pain or withdrawal

Pseudo Addiction
- in chronic pain patient

Inadequate Treatment of Pain

Apparent Drug Seeking Behavior
Effort to achieve adequate analgesia
Early refill, doctor shopping, etc.
Manipulation seen as addictive behavior
May be seen as non-compliance

Cured by adequate treatment of pain

Chronic Pain Disorder

Opioid Tolerance Opioid Physical Dependence Absence of illicit or inappropriate drug seeking behavior

No drug hunger in absence of pain No loss of control

No doctor shopping Little tendency to escalate dose over time

PSYCHOSOCIAL TREATMENT ISSUES

Population Characteristics
Heterogeneity Readiness for recovery; motivation Psychiatric comorbidity Medical comorbidity

Program Characteristics
Medical component: assessment, dosing, client interactions Individual counseling Group counseling Case management Staff training (ongoing)

What is Abstinence?

Medication is compatible with 12-step participation if appropriately prescribed by physician knowledgeable about addiction Pt on methadone is abstinent if not using illicit drugs and using legal ones as prescribed Its just another medication. Meds are a tool, not a solution

Cognitive-Behavioral Therapy
Lends itself to controlled studies; strong support for its effectiveness Especially useful to help establish abstinence, teach early recovery and relapse prevention skills Emphasizes changing behavior and managing symptoms

Cognitive Behavioral Strategies (CBT)

MATRIX MODEL - Organizing Principles Create explicit structure and expectations Establish positive, collaborative relationship Teach information and CBT concepts Positively reinforce behavior change Provide corrective feedback when necessary Encourage self-help participation

CBT: MATRIX MODEL

Structure is essential: time scheduling, selfhelp meetings, exercise, work, treatment activities Identify external and internal triggers and make a plan Tools for managing cravings: thought stopping, visual imagery, change environment/behavior TIP #33 has description, patient worksheets
(Rawson 1999)

Clinical Issues

Is Psychotherapy Useful?
Philadelphia group study, begun 1977 global psychiatric status ratings elements of drug counseling models of psychotherapy utilized benefits to low severity patients benefits to high severity patients

Dual Diagnosis Issues

depression trauma history; PTSD schizophrenia medication strategies

PTSD Influence in Early Tx

Aim: determine tx adherence relative to frequency of violence and PTSD in MMT pts, male & female 96 pts; over 2/3 exposed to one or more violent traumatic events Trauma or PTSD did not predict dropout rates Those with current PTSD had significantly more ongoing drug use at 3 months, especially cocaine

(Hein et al, 2000)

Continued heroin, alcohol, and other drug use

patient and provider expectations enhancing motivation cocaine use alcohol use medical comorbidity; AIDS, chronic pain controversies about discharge

Psychological Issues
AOD use in family of origin high frequency of childhood physical and sexual abuse recognition and appropriate expression of feelings issues of self-care, self-soothing

Womens Issues
remove practical barriers: transportation, child care intimate relationships as primary hazard sexual issues contraceptive practices

Family/Couples Work
engaging family, significant others education about addiction and MMT develop existing and new support structures couples issues parenting classes

HIV/AIDS
impact on MMT staff; providing support regular assessment of staff attitudes and knowledge integrating primary care promoting medication compliance impact of dementia on treatment

MMT and 12-Step Programs

benefits and hazards simulated meetings as a launching strategy meetings in the community Vincent Dole and Bill W. other types of self-help advocacy groups

Making Residential Treatment Available to Methadone Patients

Some clients need higher level of care Issues for the methadone program Issues for the residential program Security issues Documentation issues Funding barriers