Journal of Substance Abuse Treatment 34 (2008) 215 – 223

Regular article

The effect of methadone maintenance treatment on alcohol consumption:

A systematic review
Anita Srivastava, (M.D., M.Sc., C.C.F.P.)a,4, Meldon Kahan, (M.D., F.R.C.P.)b,
Sue Ross, (B.Sc., M.Phil., M.B.A., Ph.D.)c
a
Center for Addiction and Mental Health, University of Toronto, Toronto, ON, Canada M5S 2S1
b
Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada M5S 2S1
c
Department of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada M5S 2S1
Received 31 July 2006; received in revised form 16 March 2007; accepted 4 April 2007

Abstract

There is a high prevalence of alcohol use, abuse, and dependence in methadone maintenance treatment (MMT) programs. There have
been reports that this may be a result of entry into methadone maintenance. Through a systematic review, this article attempts to determine
whether alcohol consumption is affected during the course (from prior to treatment initiation to once on maintenance) of MMT. A literature
search for publications addressing the issue of alcohol use while on MMT was conducted. Of 15 heterogeneous clinical studies that met
inclusion criteria, three studies supported an increase in alcohol use, three supported a decrease in alcohol use, and nine supported no change
in alcohol use. The studies varied in their methodology and in their definition of problematic alcohol use. This review found that alcohol use,
although often problematic in methadone-using patients, likely does not change upon entering MMT. We recommend routine screening and
treatment for problematic alcohol use in patients on MMT. D 2008 Elsevier Inc. All rights reserved.

Keywords: Methadone maintenance; Opioid dependence; Alcohol dependence; Systematic review; Alcohol abuse

1. Introduction the nature of the relationship between alcohol and opioids is

Methadone, an opioid agonist, is the most commonly
used treatment for opioid dependence (Farrell et al., 1994).
The benefits of methadone maintenance treatment (MMT)
include improved health, decreased HIV transmission (Dole,
1989), decreased illicit behavior, and improved social and
occupational functioning (Segest, Mygind, & Bay, 1990).
However, despite the beneficial effects of methadone, it has
been suggested that methadone treatment may lead to an
increase in alcohol use and dependence (Backmund, Schütz,
Meyer, Eichenlaub, & Soyka, 2003; D’Aunno &Vaughn,
1992; Gelb, Richman, & Anand, 1978; Green & Jaffe, 1977;
Kreek, 1984), which causes significant disability and places
a large burden on health care resources. Thus, establishing
4 Corresponding author. Center for Addiction and Mental Health,
University of Toronto, 33 Russell Street, Toronto, ON, Canada M5S 2S1.
E-mail address: anita_srivastava@camh.net (A. Srivastava).
important from a clinical perspective, as improved aware-
ness would be useful in planning treatment for opioid-
dependent patients with concurrent alcohol use.
Varying associations between MMT and alcohol use
have been reported. It has been established that there is a
high incidence of alcohol dependence in methadone-using
patients compared to the general population (Hunt et al.,
1986), with the prevalence of alcohol dependence in
methadone-using patients ranging from 13% to 31% in
various studies (Cohen et al., 1982; Joseph & Appel,
1985; Ottomanelli, 1999; Statsny & Potter, 1991). Varia-
tions in prevalence are likely because of different
definitions of problematic alcohol use and the variety of
populations studied.
It has been shown that methadone-using patients who
drink are at a significantly greater risk for cirrhosis,
esophageal varices, and other medical complications (Stim-
mel, Vernace, & Tobias, 1972). Higher death rates and

0740-5472/08/$ – see front matter D 2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.jsat.2007.04.001
 216
Table 1
Reviewed studies in chronological order of publication
Measurement Daily
Study design/ Mean follow-up parameters for Change in alcohol methadone
Year Study title Authors Sample size Sample methodology time alcohol Outcome consumption dose
1973, Alcohol Use by Schut et al., 100 MMT Retrospective cohort Patients had been on Self-report of relative Trend toward increased Increase (statistical Not stated
United Narcotic Addicts in 1973 outpatients (by interview) of MMT for a mean of changes (bmuch alcohol consumption significance not
States Methadone alcohol consumption 18 months at the time more,Q bmore,Q bthe while on MMT; 20% reported, based on
Maintenance at four different of the study same,Q bless,Q bmuch reported drinking bmoreQ authors’ conclusions)
Treatment phases: bfirst use of less,Q and bnot at allQ) or bmuch moreQ than
drugs,Q bfirst use of at four stages of drug before MMT, 68% did
narcotics,Q bdaily use not drink before MMT,

A. Srivastava et al. / Journal of Substance Abuse Treatment 34 (2008) 215 – 223

1978, Alcohol Use in the
United Opiate Use Cycle of
States the Heroin Addict
1980, Risk for Alcoholism
United and Methadone
States Treatment. A
Longitudinal Study
1982, Alcoholism as a Risk Stimmel
United Factor in Methadone et al., 1982
States Maintenance. A
Randomized
Controlled Trial
narcotic use,Q and but only 38% did not
bon MMTQ drink after an average of
18 months on methadone
Green et al., 96 MMT Retrospective cohort Patients had been on Categorized subjects The rate of balcoholic,Q No change (statistical Not stated
1978 outpatients of alcohol MMT for a mean into five drinking bproblem,Q and bheavyQ significance not
consumption at duration of 28 patterns of drinking was 32% during reported, based on
different phases of months at the time balcoholic,Q heroin use and 42% authors’ conclusions)
lifetime baddiction of the study bproblem,Q bheavy,Q while on MMT, and most
cycleQ and MMT bmoderate,Q or of this group had a
bexperimentalQ history of excessive
versus babstainer,Q as alcohol intake prior to
well as those who MMT; the lifetime
met the study’s prevalence of alcoholism
definition of the was 26% in the sample,
lifetime prevalence and the point prevalence
of alcoholism in MMT was 10–11%;
authors concluded little
development of new
excessive drinking
while on MMT
Marcovici 60 Male veterans Prospective cohort; 6 months MAST, breathalyzer, No significant changes No change The mean dose
et al., 1980 on admission veterans were laboratory values and were observed in alcohol at 6 months for
to MMT followed at monthly interviews, and NCA consumption in bproblemQ
intervals with criteria were all used bproblemQ or bnormalQ drinkers was
respect to alcohol to categorize drinkers drinkers after 6 months 45–50 mg and
consumption into bnormalQ or on MMT for bnormal
bproblemQ drinkers drinkersQ was
35–40 mg
625; 512 Patients entering Prospective cohort; 53.7 weeks Subjects were Two-day alcohol Decrease Not stated
on follow-up MMT program in patients were classified into active, consumption and
tertiary care centers followed with inactive, or nonactive BAL significantly
in New York city respect to alcohol alcoholics using decreased in all subjects
consumption NCA criteria; they over time on treatment,
had quarterly but the decrease was
assessments: NCA most significant in
criteria, 2-day active alcoholics,
maximum alcohol although, overall,
consumption active alcoholics had
histories, BALs, and greater consumption
daily alcohol intake
in the preceding
30 days
1982, Alcohol Jackson et al., 625; 512 Patients on MMT in Prospective cohort 53.7 weeks Maximum 2-day alcohol Two-day alcohol Decrease Not stated
United Consumption in 1982 on follow-up an urban tertiary care followed with consumption in the last consumption
States Persons on setting; entering respect to their 3 months based on significantly decreased
Methadone patients alcohol quarterly self-reports for in all participants during
Maintenance consumption 596 patients; BAL and study enrollment
Therapy self-reports available for
342 patients
1982, The Significance Rounsaville 157; 123 Patients starting on Prospective cohort 6 months RDC for alcoholism Entrance into treatment No change Not stated
United of Alcoholism in et al., 1982 on follow-up an MMT program with follow-up at does not lead to change in
States Treated Opiate 6 months alcohol abuse: 84% had no
Addicts change in alcohol use,
11% had decreased
alcohol use, and 5% had
increased alcohol use
1989, Alcohol Use by Anglin et al., 375; 181 Nonmethadone A retrospective 60 months for Amount of alcohol Alcohol consumption Increase Not stated

A. Srivastava et al. / Journal of Substance Abuse Treatment 34 (2008) 215 – 223

United Heroin Addicts: 1989 on methadone (bdrug-freeQ) cohort; subjects non-methadone- consumption (z6 increased as heroin use
States Evidence for an treatment outpatients/inpatients interviewed with using patients and drinks in a 6-hour decreased in both
Inverse (n = 194) and MMT respect to alcohol 20 months for period at least twice non-methadone-using
Relationship. A outpatients and heroin methadone-using a week) at various and methadone-using
Study of Methadone (n = 181); all male consumption at patients stages of drug use patients
Maintenance and different phases of
Drug-Free drug use/treatment
Treatment Samples
1990, Opioid Addiction Simpson 175 Opioid-dependent Prospective cohort 12 years Self-report on alcohol Alcohol consumption No change (statistical Not stated
United and Treatment: & Sells, 1990 patients use; alcohol use increased after the significance was
States A 12-Year measured as greater first year of treatment, confirmed by
Follow-Up than either 4 oz daily but there were no other correspondence with
or 8 oz daily of significant changes author)
absolute alcohol in alcohol consumption
over 12 years
1993, Do Methadone Fairbank et al., 513 Heroin users Multicenter 1 year Structured interviews; Overall reduction in the No change Not stated
United Patients Substitute 1993 admitted to MMT prospective cohort heavy alcohol use use of several drugs, except
States Other Drugs for programs followed for drug defined as z5 drinks/ for alcohol at 1-year fol
Heroin? Predicting use from admission day in the last 90 days low-up after MMT
Substance Use at to 1-year follow-up enrolment; alcohol use was
1-Year Follow-Up (whether still on constant before and 1 year
MMT) after MMT admission for
both patients still on MMT
and those off the program
1996, Buprenorphine Strain et al., 164; 84 in Intravenous- Double-blind RCT; 16 weeks Outcomes relevant to No significant No change Doses ranging
United Versus Methadone 1996 buprenorphine opioid-dependent 80 patients enrolled alcohol consumption: change in alcohol from 50 to
States in the Treatment of arm and 80 in patients in the MMT arm ASI for those patients parameters over the 90 mg;
Opioid Dependence: MMT arm who remained on 16-week period for average dose
Self-Reports, (43 completed the treatment for the entire those remaining on of 54 mg/day
Urinalysis, and MMT arm) 16-week period; the treatment; however,
Addiction Severity alcohol section of the the number of days
Index ASI included the number using cocaine
of days drinking in the decreased over time
last 30 days, amount of in the methadone arm
dollars spent on alcohol
in the last 30 days,
number of days drinking
to intoxication in the last
30 days, patient rating
on the need for
treatment, and overall
composite score

217
(continued on next page)
 218
Table 1 (continued)
Measurement Daily
Study design/ Mean follow-up parameters for Change in alcohol methadone
Year Study title Authors Sample size Sample methodology time alcohol Outcome consumption dose
1998, Prognostic Factors in Schottenfeld 116; 58 subjects Patients who were RCT; 28 patients 22 weeks Weekly patient self- No significant effect of No change 65 mg for 28
United Buprenorphine- et al., 1998 in the MMT arm opioid dependent and randomized to 65 mg reports of the total MMT on the number of patients; 20 mg
States Versus Methadone- and 58 in the had cocaine of methadone and 30 number of standard reported days using alcohol; for 30 patients
Maintained buprenorphine dependence/abuse patients randomized drinks and the number effects of time were not
Patients arm to 20 mg of of days using alcohol in significant for alcohol use
methadone the preceding week
over a period of
22 weeks
2000, UK Patterns of Gossop et al., 458; 333 on Patients from Longitudinal 414 days UK Royal College of No change from intake No change Average dose

A. Srivastava et al. / Journal of Substance Abuse Treatment 34 (2008) 215 – 223

Improvement After 2000 follow-up community prospective cohort Psychiatrists to follow-up in the overall at 1 year was
Methadone methadone programs recommendations for percentage of patients who 52.3 mg
Treatment: 1 Year (either maintenance sensible drinking were drinking above safe
Follow-Up Results or gradual reduction guidelines (approximately
From the National programs) 25% before and after in
Treatment Outcome both reduction and
Research Study maintenance groups)
2000, UK Randomized Trial of Strang et al., 40 Intravenous-opioid- RCT; patients 6 months Number of days of No change in the No change Mean dose for
Supervised Injectable 2000 dependent patients randomized to oral alcohol use in the last frequency of alcohol oral patients on
Versus Oral or injectable 30 days, as use in both MMT was
Methadone methadone; 15 ascertained by oral-methadone- 79.6 mg and
Maintenance: Report completed oral personal interview using patients and for injectable
of Feasibility and treatment and 18 injectable- patients was
6-Month Outcome completed injectable methadone-using 96.6 mg
treatment patients
2000, Alcohol Rittmannsberger 68 MMT outpatients on Retrospective study 50 months Alcohol indicators, The number of patients Increase Not stated
Austria Consumption During et al., 2000 treatment for a from admission to including self-reports reporting frequent alcohol
Methadone minimum of 1 year follow-up at the time on the frequency of use increased from 19%
Maintenance of the study alcohol use and to 33% during MMT,
Treatment biochemical markers but this was not significant;
(BAL) the overall proportion
with balcohol indicatorsQ
was constant at the start
of MMT and on follow-up,
but biochemical markers
significantly increased in
those with preexisting
balcohol indicatorsQ and,
thus, intensity of alcohol
consumption probably
increased
2002, Short-Term Caputo et al., 327; 105 in the Nonalcoholic heroin- Prospective clinical 4 weeks Amount of alcohol During the first 4 weeks Decrease Maximum of
Italy Methadone 2002 methadone group addicted patients cohort; assessed on intake (g/day) was of treatment, alcohol 120 mg/day;
Administration during the first admission and at assessed by consumption significantly flexible dosing
Reduces Alcohol 4 weeks of either an 1 month into self-report and decreased in patients on
Consumption in MMT program treatment family member MMT, but not in non-
Non-Alcoholic (n = 105) or a interview on methadone-using patients
Heroin Addicts non-MMT program admission and at the
(n = 222) end of the first 4
weeks; urine, blood,
and saliva alcohol
concentrations
 A. Srivastava et al. / Journal of Substance Abuse Treatment 34 (2008) 215 – 223
medical illness have also been reported among alcohol-using
patients on methadone (Rowan-Szal, Chatham, & Simpson,
2000), with alcohol playing a significant role (Gossop,
Stewart, Browne, & Marsden, 2003). In hepatitis C infection,
which is prevalent in patients on MMT, alcohol use causes
more severe and rapidly progressive liver cirrhosis and
hepatocellular carcinoma (Schiff, 1997). Since the advent of
screening programs, intravenous drug use has replaced
transfusion as the major route of hepatitis C infection in
North America (Feng, 1999). The prevalence of hepatitis C in
intravenous drug users ranges from 69% to 88% (Cullen,
Bury, Barry, & O’Kelly, 2003; Novick, 2000; Selvey, Denton,
& Plant, 1997), and two studies of methadone programs
reported an 84% and a 96% prevalence of hepatitis C among
their patients (Chetwynd, Brunton, Blank, Plumridge, &
Baldwin, 1995; McCarthy & Flynn, 2001).
Fortunately, treatment of alcohol dependence, although
not curative, has shown to be effective (O’Malley et al.,
1992; Volpicelli, Alteerman, Hayashida, & O’Brien, 1992).
As well, preliminary studies have shown that the treatment
of alcohol dependence in methadone-using patients can be
effective (Bickel et al., 1989). Therefore, awareness of the
potential influence of MMT on alcohol consumption is
important, as early recognition and treatment of alcohol
dependence in patients could have a major impact on
treatment outcomes.
Three previously published reviews have examined the
relationship between alcohol and opiates (Green & Jaffe,
1977; Herz, 1997; Ottomanelli, 1999). Green and Jaffe
concluded that excessive alcohol use is high among
narcotic-addicted patients compared to the general popula-
tion. However, the reviewers concluded that whether
methadone contributed to alcohol consumption remained
unclear from available published reports at that time. A later
review by Herz examined the role of endogenous opioid
systems and alcohol dependence from a pharmacological
perspective. A more recent review (Ottomanelli, 1999)
suggested that, although the rate of alcohol dependence
among methadone-using patients was higher than that of the
general population, it was comparable to individuals in
high-stress situations. However, although comprehensive,
none of these reviews was designed to examine the change
in alcohol consumption over time while subjects were
enrolled in an MMT program.
Thus, we set out to conduct a systematic review of
clinical studies examining changes in problematic alcohol
use upon commencing and being maintained on meth-
adone treatment, with the intent of making suggestions for
the clinical management of alcohol use by patients in
MMT programs.
2. Materials and methods
A literature search was carried out using the medical
database Medline, PsychInfo, and the Cochrane database.
219
The search terms bopioids,Q bopiates,Q bmethadone,Q
bheroin addicts,Q baddiction,Q and balcoholQ were cross-
referenced in the databases. A full search strategy is
available upon request.
Abstracts of all publications possibly related to the
review were read by one author (A.S.). Full publications
were obtained for those studies believed to be relevant.
Clinical studies of any design, related to human subjects,
in English, and specifically examining changes in alcohol
use during the course (from prior to treatment initiation to
during the maintenance phase) of MMT were included.
Studies were excluded if they were animal studies or if
they focused primarily on the prevalence or etiological
factors of alcohol use while on methadone maintenance.
Studies that did not investigate changes in alcohol
consumption patterns as a result of starting and being
maintained on MMT were also excluded. One additional
landmark study was identified in addition to the literature
search and was added to our study.
A data collection form was developed to systematically
abstract information for each article on study design, sample
population, sample size, follow-up time, measurement
parameters, and outcomes. Data were extracted by A.S.,
and all details were checked by S.R.
Qualitative methods were used to synthesize the results.
Studies were grouped together according to whether they
found alcohol consumption to have increased, stayed the
same, or decreased on MMT. If it was unclear whether
results were statistically significant, an attempt was made to
contact the original authors: If unavailable, the results were
reported as being bbased on authors’ conclusionsQ (Table 1).
3. Results
The search in the database Medline yielded 690
publications, with no additional relevant publications
identified from the Cochrane database. Of the 690 articles,
41 were thought to be possibly relevant from their abstracts,
and full articles were obtained. Fourteen of the 41 articles
fulfilled our inclusion criteria and assessed alcohol use prior
to MMT initiation and then again at some point during
maintenance treatment.
The 14 articles (Table 1) reported 13 study populations
(two articles utilized the same patient population but
measured different outcome parameters; Jackson et al.,
1982; Stimmel et al., 1982) and were published between
1973 and 2002. The additional landmark study in this area
was the Drug Abuse Reporting System (DARP) study,
which was summarized in a book (Simpson & Sells, 1990).
Thus, the total number of studies included in this review
was 15. Eleven of the 15 studies were carried out in the
United States, two in the UK, one in Italy, and one in
Austria. Twelve articles were cohort studies (either retro-
spective or prospective), and three were randomized
controlled trials (RCTs; Schottenfeld, Pakes, & Kosten,
220 A. Srivastava et al. / Journal of Substance Abuse Treatment 34 (2008) 215 – 223
1998; Strain, Stitzer, Liebson, & Bigelow, 1996; Strang
et al., 2000). The reported length of follow-up varied from
4 weeks to 12 years.
Several instruments to assess alcohol consumption were
employed by the different studies. Some (Anglin, Almog,
Fisher, & Peters, 1989; Caputo et al., 2002; Fairbank,
Duntenan, & Coldelli, 1993; Green, Jaffe, Carlisi, & Zaks,
1978; Jackson et al., 1982; Schottenfeld et al., 1998;
Schut, File, & Wohlmuth, 1973; Simpson & Sells, 1990)
looked primarily at alcohol consumption (either quantita-
tively or by ordinal ranking) rather than defining alcohol
dependence. Most studies considered several parameters,
including the National Council on Alcoholism’s (NCA’s)
definition of alcohol dependence (Marcovici, McLellan,
O’Brien, & Rosenzweig, 1980; Stimmel et al., 1982),
blood alcohol levels (BALs; Caputo et al., 2002; Jackson
et al., 1982; Marcovici et al., 1980; Rittmannsberger,
Silberbauer, Lehner, & Ruschak, 2000; Stimmel et al.,
1982), the alcohol section of the composite Addiction
Severity Index (ASI) score (Strain et al., 1996), the
frequency of alcohol use in varying defined periods
(Anglin et al., 1989; Fairbank et al., 1993; Rittmanns-
berger et al., 2000; Schottenfeld et al., 1998; Simpson &
Sells, 1990; Strain et al., 1996; Strang et al., 2000), and
biochemical markers (Rittmannsberger et al., 2000).
Patient populations varied between studies, although the
majority focused on MMT outpatients in urban settings.
Some studies involved only heroin or intravenous opiate
users (Caputo et al., 2002; Fairbank et al., 1993; Strain et al.,
1996; Strang et al., 2000), whereas others did not specify the
type of opioid dependency. One study (Marcovici et al.,
1980) enrolled only male veterans, and another study
(Schottenfeld et al., 1998) included only patients who were
opioid dependent and had cocaine dependence or abuse,
whereas the most recent study only assessed patients with
no previous history of alcohol dependence (Caputo et al.,
2002). Thus, the populations assessed were not homoge-
neous. Sample sizes varied between 40 and 625 participants.
Of the 15 reviewed studies, three (Anglin et al., 1989;
Rittmannsberger et al., 2000; Schut et al., 1973) supported
an increase in alcohol consumption on MMT, nine (Fair-
bank et al., 1993; Gossop, Marsden, Stewart, & Rolfe, 2000;
Green et al., 1978; Marcovici et al., 1980; Rounsaville,
Weissman, & Kleber, 1982; Schottenfeld et al., 1998;
Simpson & Sells, 1990; Strain et al., 1996; Strang et al.,
2000) reported no change in alcohol consumption, and three
(Caputo et al. 2002; Jackson et al., 1982; Stimmel et al.,
1982) studies (two of which used the exact same sample:
Jackson et al., 1982; Stimmel et al., 1982) found that
alcohol consumption decreased while on MMT. Most of the
studies reported statistical analyses; in two cases (Green
et al., 1978; Schut et al., 1973), there was no statistical
analysis reported, and as we were unsuccessful in contacting
the authors, we relied on the stated conclusions of the
investigators. There was no obvious temporal trend in the
study results over the review period (1973–2002).
3.1. Increase in alcohol consumption over time
Three studies, all retrospective, found an increase in
alcohol consumption while on MMT.
Schut et al.’s (1973) study of methadone outpatients
asked participants about relative changes in alcohol con-
sumption (bmuch more,Q bmore,Q bthe same,Q bless,Q bmuch
less,Q and bnot at allQ) at different phases of drug use and
treatment (first use of drugs, first use of narcotics, daily
narcotic use, and on MMT treatment; Schut et al., 1973).
Sixty-eight percent of patients reported that they did not use
alcohol at all during daily narcotic use; however, after an
average of 18 months on methadone treatment, only 38%
reported not using any alcohol at all and 20% reported
drinking bmoreQ or bmuch moreQ than prior to treatment.
Anglin et al. (1989), in their retrospective study of male
heroin-addicted patients, found that alcohol consumption
increased during methadone treatment. However, the
authors concluded that the increased alcohol consumption
observed in patients on MMT was not causally related to
MMT because the increase was also observed in a non-
MMT treatment group. In addition, alcohol use increased
during any phase when opiate use decreased (i.e., they
found an inverse relationship between alcohol use and
narcotic use). The study included only patients who were no
longer in treatment, suggesting that there would have been a
time lapse between treatment and the time of the interview.
Rittmannsberger et al. (2000) investigated a group of
68 methadone-using patients undergoing MMT for a mean
duration of 50 months and found that, although the number
of patients reporting frequent alcohol use increased from
19% from before the initiation of MMT to 33% during
MMT, it was not significant. However, they also hypothe-
sized that the intensity of alcohol consumption probably
increased in those with preexisting problematic alcohol use
because of a significant increase in biochemical markers in
this group, although it is important to note that they did not
directly assess alcohol consumption before the beginning of
treatment or at the time of follow-up.
3.2. No change in alcohol consumption
Nine studies found that there was no change in alcohol
consumption while on MMT.
Green et al. (1978) conducted a retrospective survey
of alcohol use on patients who had been on MMT
for an average of 28 months. Patients were categorized
into five defined drinking patterns of balcoholic,Q
bproblem,Q bheavy,Q bmoderate,Q and bexperimentalQ versus
babstainer.Q The rate of excessive (balcoholic,Q bproblem,Q
or bheavyQ) use was 32% during heroin use and 42% while
on MMT, whereas the lifetime prevalence of alcoholism in
the entire sample was 26% versus the 10–11% point
prevalence in the methadone group. The authors concluded
that that there was little development of new excessive
drinking while on MMT.
 A. Srivastava et al. / Journal of Substance Abuse Treatment 34 (2008) 215 – 223
Marcovici et al. (1980) found that in a 6-month
prospective cohort of male veterans, there was no change
in alcohol consumption in either bnormalQ or bproblemQ
drinkers as measured by the Michigan Alcoholism Screen
Test (MAST), BAL, laboratory values, interviews, and
NCA criteria.
Rounsaville et al. (1982) found that 84% of their
prospective cohort did not have a change in alcohol
consumption, as measured by Research Diagnostic Criteria
(RDC), as a result of entering into methadone treatment.
Simpson and Sells (1990), who studied the DARP,
followed 175 patients on methadone maintenance for
12 years and assessed alcohol consumption at 1, 2, 3, 6, and
12 years. They concluded that there was an overall stability
of alcohol consumption during treatment.
Fairbank et al. (1993) followed 513 heroin users admitted
to MMT and found that there was a decline in the use of all
substances (cocaine, amphetamines, tranquilizers, mari-
juana, and illegal methadone) at 1 year. Alcohol was a
notable exception: Heavy alcohol use (defined as N 5 drinks/
day for the last 90 days) remained constant from preadmis-
sion (28%) to follow-up 1 year later (26%), regardless of
whether patients were still on methadone.
Strain et al. (1996) randomized intravenous-opioid-
dependent patients to either buprenorphine or MMT and
followed them for 16 weeks. The patients who were
enrolled in the methadone arm did not have a statistically
significant change at either 6 or 16 weeks in the alcohol
component (including the number of days drinking to
intoxication in the last 30 days) of their ASI scores.
Schottenfeld et al. (1998) also randomized patients to
either methadone or buprenorphine and found that, after 22
weeks of maintenance, there was no significant effect of
MMT on the number of reported days using alcohol and the
number of standard drinks consumed.
Gossop et al. (2000) followed a cohort of patients for a
mean of 414 days and, using the UK Royal College of
Psychiatrists’ recommendations for sensible drinking, found
that there was no change from intake to follow-up in the
overall percentage of patients who were drinking above safe
guidelines, although there was reduction in the use of illicit
stimulant, benzodiazepine, or opiate.
Strang et al. (2000) found that in their RCT of patients
randomized to oral or injectable methadone for 6 months,
there was no change in the frequency of alcohol used in the
last 30 days in either group, although benzodiazepine and
crack/cocaine use decreased.
3.3. Decrease in alcohol consumption over time
Of the three articles that found a decrease in alcohol
consumption, two were based on the same sample of
patients: Jackson et al. (1982) and Stimmel et al. (1982)
included both alcohol-dependent and non-alcohol-depend-
ent populations starting MMT. Decrease in alcohol con-
sumption occurred in both of these groups, but the group
221
that had the greatest alcohol consumption overall (bactive
alcoholicsQ) also had the greatest decrease in alcohol
consumption over time. Alcohol consumption was assessed
quarterly using NCA criteria, 2-day maximum alcohol
consumption in the last quarter, BAL, and daily alcohol
intake in the preceding 30 days.
Caputo et al. (2002) found that in non-alcohol-dependent
heroin-addicted patients, alcohol intake decreased after 4
weeks on methadone treatment but not among those in
nonmethadone treatment. Alcohol consumption was meas-
ured as grams per day of absolute alcohol, as determined by
self-report and family member interviews.
4. Discussion
Overall, the results of our review did not support an
increase in alcohol consumption after initiation and
maintenance on methadone. Although three of the studies
(Anglin et al., 1989; Rittmannsberger et al., 2000; Schut
et al., 1973) found that there was an increase in alcohol
consumption on MMT, nine (Fairbank et al., 1993; Gossop
et al., 2000; Green et al., 1978; Marcovici et al., 1980;
Rounsaville et al., 1982; Schottenfeld et al., 1998;
Simpson & Sells 1990; Strain et al., 1996; Strang et al.,
2000) found that there was no change, and three (Caputo
et al. 2002; Jackson et al., 1982; Stimmel et al., 1982)
studies (two of which employed the same study popula-
tion) found that there was a decrease in alcohol con-
sumption. Moreover, the studies that found no change in
consumption or a decrease in consumption were stronger
methodologically as they were collectively three RCTs and
seven prospective cohorts, whereas the studies that found
increases in alcohol consumption were all retrospective in
design and subject to recall bias. Thus, rather than
supporting a view that alcohol consumption increases after
initiation and maintenance on methadone, our review
found that alcohol consumption likely does not change
when patients are on MMT.
However, this result is complicated by the heterogeneity
of the reviewed studies. Different sample populations,
designs, measurement parameters, and times of follow-up
complicated our review. Our findings must be viewed with
some caution as making direct comparisons between studies
is difficult. The reviewed studies used different outcome
measures, including directly quantifying alcohol intake,
drinking beyond safe guidelines, meeting criteria for alcohol
dependence, and laboratory parameters.
Another factor that may cause problems for studies is the
possibility that alcohol consumption oscillates in metha-
done-using patients (Bickel & Rizzuto, 1991). Thus, the
waxing and waning of alcohol consumption and the time of
assessment may have had an impact on the conclusions of
the studies included in the review.
With the increasing acceptance and use of MMT, the
issue of codependence and coabuse of other substances,
222 A. Srivastava et al. / Journal of Substance Abuse Treatment 34 (2008) 215 – 223
including alcohol, has much clinical relevance. Although we
concluded that alcohol consumption likely stayed constant,
it is interesting to note that in two of the reviewed studies
(Gossop et al., 2000; Strang et al., 2000) in which alcohol
use did not change, the use of other illicit substances
decreased. This suggests that the stability of alcohol
consumption is problematic and that methadone mainte-
nance programs should prioritize addressing the issue of
alcohol use in methadone maintenance programs.
Clinicians should screen all methadone-using patients for
alcohol abuse and dependence, and offer appropriate treat-
ment. There is some preliminary evidence that the treatment
of alcohol dependence in methadone treatment may result in
better outcomes for patients, including such treatments as
disulfiram (Green & Jaffe, 1977) or behavioral–pharmaco-
logical treatments (Bickel, Marion, & Lowinson, 1987).
There is also evidence that there is benefit to harm-reduction
strategies for alcohol use in methadone-using patients with
hepatitis C infection (McCusker, 2001).
Although evidence regarding the treatment of alcohol
abuse and dependence in patients on methadone mainte-
nance is limited, there is good evidence for treating alcohol
dependence in general (Johnson, 2004a, 2004b; Mann,
2004; Mann, Lehert, & Morgan, 2004): Options include
supportive counseling and pharmacological agents such as
disulfiram, acamprosate, naltrexone, and topiramate. How-
ever, although this evidence on the efficacy of alcohol
dependence treatment likely extends to methadone-using
patients (except for naltrexone, which would be contra-
indicated in the methadone-using patient), areas for future
research include specifically examining the efficacy of
screening and treatment modalities as possible inherent
components of MMT.
Better awareness and treatment planning is necessary to
avoid the additional morbidity and mortality caused by
problematic alcohol use, which remains an unfortunate part
of many methadone-using patients’ lives.
References
Anglin, M. D., Almog, I. J., Fisher, D. G., & Peters, K. R. (1989). Alcohol
use by heroin addicts: Evidence for an inverse relationship. A study of
methadone maintenance and drug-free treatment samples. American
Journal of Drug and Alcohol Abuse, 15, 191 – 207.
Backmund, M., Schütz, C. G., Meyer, K., Eichenlaub, D., & Soyka, M.
(2003). Alcohol consumption in heroin users, methadone-substituted
and codeine-substituted patients—Frequency and correlates of use.
European Addiction Research, 9, 45 – 50.
Bickel, W. K., Marion, I., & Lowinson, J. H. (1987). The treatment of
alcoholic methadone patients: A review. Journal of Substance Abuse
Treatment, 4, 15 – 19.
Bickel, W. K., & Rizzuto, P. (1991). The naturalistic oscillating patterns of
alcohol consumption in alcoholic methadone patients. Journal of
Studies on Alcohol, 52, 454 – 457.
Bickel, W. K., Rizzuto, P., Zielony, R. D., Klobas, J., Pangiosonlis, P.,
Mernit, R., et al. (1989). Combined behavioral and pharmacological
treatment of alcoholic methadone patients. Journal of Substance Abuse,
1, 161 – 171.
Caputo, F., Addolorato, G., Domenicalli, M., Mosti, A., Viaggi, M.,
Trevisani, F., et al. (2002). Short-term methadone administration
reduces alcohol consumption in non-alcoholic heroin addicts. Alcohol,
37, 164 – 168.
Chetwynd, J., Brunton, C., Blank, M., Plumridge, E., & Baldwin, D.
(1995). Hepatitis C seroprevalence amongst injecting drug users
attending a methadone programme. New Zealand Medical Journal,
108, 364 – 366.
Cohen, M., Korts, D., Hanbury, R., Sturiano, V., Jackson, G., & Stimmel,
B. (1982). The effect of alcoholism in methadone-maintained persons
on productive activity: A randomized control trial. Alcoholism, Clinical
and Experimental Research, 6, 358 – 361.
Cullen, W., Bury, G., Barry, J., & O’Kelly, F. (2003). Hepatitis C (HCV)
infection among drug users attending general practice. Irish Journal of
Medical Science, 172, 123 – 127.
D’Aunno, T., & Vaughn, T. E. (1992). Variations in methadone treatment
practices. Results from a national study. Journal of the American
Medical Association, 267, 253 – 258.
Dole, V. P. (1989). Methadone treatment and the acquired immunodefi-
ciency syndrome epidemic. Journal of the American Medical Associ-
ation, 262, 1681 – 1682.
Fairbank, J. A., Dunteman, G. H., & Condelli, W. S. (1993). Do methadone
patients substitute other drugs for heroin? Predicting substance use at 1-
year follow-up. American Journal of Drug and Alcohol Abuse, 19,
465 – 474.
Farrell, M., Ward, J., Mattick, R., Hall, W., Stimson, G. V., Jarlais, D., et al.
(1994). Methadone maintenance treatment in opiate dependence: A
review. British Medical Journal, 309, 997 – 1001.
Feng, X. (1999). Hepatitis C infection: A review. Lippincott’s Primary Care
Practice, 3, 345 – 353.
Gelb, A. M., Richman, B. L., & Anand, O. P. (1978). Quantitative and
temporal relationships of alcohol use in narcotic addicts and methadone
maintenance patients undergoing alcohol detoxification. American
Journal of Drug and Alcohol Abuse, 5, 191 – 198.
Gossop, M., Marsden, J., Stewart, D., & Rolfe, A. (2000). Patterns of
improvement after methadone treatment: 1 year follow-up results from
the National Treatment Outcome Research Study. Drug and Alcohol
Dependence, 60, 275 – 286.
Gossop, M., Stewart, D., Browne, N., & Marsden, J. (2003). Methadone
treatment for opiate dependent patients in general practice and specialist
clinic settings: Outcomes at 2-year follow-up. Journal of Substance
Abuse Treatment, 24, 313 – 321.
Green, J., Jaffe, J., Carlisi, J. A., & Zaks, A. (1978). Alcohol use in the
opiate use cycle of the heroin addict. International Journal of the
Addictions, 13, 1021 – 1033.
Green, J., & Jaffe, J. H. (1977). Alcohol and opiate dependence; a review.
Journal of Studies on Alcohol, 38, 1274 – 1293.
Herz, A. (1997). Endogenous opioid systems and alcohol addiction.
Psychopharmacology, 129, 99 – 111.
Hunt, D. E., Strug, D. L., Goldsmith, D. S., Lipton, D. S., Robertson, K., &
Truitt, L. (1986). Alcohol use and abuse: Heavy drinking among
methadone clients. American Journal of Drug and Alcohol Abuse, 12,
147 – 164.
Jackson, G., Korts, D., Hanbury, R., Sturiano, V., Wolpert, L., Cohen, M.,
et al. (1982). Alcohol consumption in persons on methadone
maintenance therapy. American Journal of Drug and Alcohol Abuse,
9, 69 – 76.
Johnson, B. A. (2004a). An overview of the development of medications
including novel anticonvulsants for the treatment of alcohol depend-
ence. Expert Opinion on Pharmacotherapy, 5, 1943 – 1955.
Johnson, B. A. (2004b). Progress in the development of topiramate for
treating alcohol dependence: From a hypothesis to a proof-of-
concept study. Alcoholism: Clinical and Experimental Research, 28,
1137 – 1144.
Joseph, H., & Appel, P. (1985). Alcoholism and methadone treatment:
Consequences for the patient and program. American Journal of Drug
and Alcohol Abuse, 11, 37 – 53.
 A. Srivastava et al. / Journal of Substance Abuse Treatment 34 (2008) 215 – 223
Kreek, M. J. (1984). Opioid interactions with alcohol. Advances in Alcohol
& Substance Abuse, 3, 35 – 46.
Mann, K. (2004). Pharmacotherapy of alcohol dependence: A review of the
clinical data. CNS Drugs, 18, 485 – 504.
Mann, K., Lehert, P., & Morgan, M. Y. (2004). The efficacy of acamprosate
in the maintenance of abstinence in alcohol-dependent individuals:
Results of a meta-analysis. Alcoholism: Clinical and Experimental
Research, 28, 51 – 63.
Marcovici, M., McLellan, T., O’Brien, C., & Rosenzweig, J. (1980). Risk
for alcoholism and methadone treatment. A longitudinal study. Journal
of Nervous and Mental Disease, 168, 556 – 558.
McCarthy, J. J., & Flynn, N. (2001). Hepatitis C in methadone maintenance
patients: Prevalence and public policy implications. Journal of
Addictive Diseases, 20, 19 – 31.
McCusker, M. (2001). Influence of hepatitis C status on alcohol
consumption in opiate users in treatment. Addiction, 96, 1007 – 1014.
Novick, D. M. (2000). The impact of hepatitis C virus infection on
methadone maintenance treatment. Mount Sinai Journal of Medicine,
67, 437 – 443.
O’Malley, S. S., Jaffe, J., Chang, G., Schottenfeld, R. S., Meyer, R. E., &
Rounsaville, B. (1992). Naltrexone and coping skills therapy for alcohol
dependence. A controlled study. Archives of General Psychiatry, 49,
881 – 887.
Ottomanelli, G. (1999). Methadone patients and alcohol abuse. Journal of
Substance Abuse Treatment, 16, 113 – 121.
Rittmannsberger, H., Silberbauer, C. H., Lehner, R., & Ruschak, M. (2000).
Alcohol consumption during methadone maintenance treatment. Euro-
pean Addiction Research, 6, 2 – 7.
Rounsaville, B. J., Weissman, M. M., & Kleber, H. D. (1982). The
significance of alcoholism in treated opiate addicts. Journal of Nervous
and Mental Disease, 170, 479 – 488.
Rowan-Szal, G. A., Chatham, L. R., & Simpson, D. D. (2000). Importance
of identifying cocaine and alcohol dependent methadone clients.
American Journal on Addictions, 9, 38 – 50.
Schiff, E. R. (1997). Hepatitis C and alcohol. Hepatology, 26, 39S – 42S.
223
Schottenfeld, R. S., Pakes, J. R., & Kosten, T. R. (1998). Prognostic factors
in buprenorphine- versus methadone-maintained patients. Journal of
Nervous and Mental Disease, 186, 35 – 43.
Schut, J., File, K., & Wohlmuth, T. (1973). Alcohol use by narcotic addicts
in methadone maintenance treatment. Quarterly Journal of Studies on
Alcohol, 34, 1356 – 1359.
Segest, E., Mygind, O., & Bay, H. (1990). The influence of prolonged stable
methadone maintenance treatment on mortality and employment: An
8-year follow-up. International Journal of the Addictions, 25, 53 – 63.
Selvey, L. A., Denton, M., & Plant, A. J. (1997). Incidence and prevalence
of hepatitis C among clients of a Brisbane methadone clinic: Factors
influencing hepatitis C serostatus. Australian and New Zealand Journal
of Public Health, 21, 102 – 104.
Simpson D. D., & Sells S. B. (Eds.), (1990). Opioid addiction and treatment:
A 12-year follow-up (p. 57) . Malobar, FL7 Robert E. Krieger Publishing.
Stastny, D., & Potter, M. (1991). Alcohol abuse by patients undergoing
methadone treatment programmes. British Journal of Addiction, 86,
307 – 310.
Stimmel, B., Hanbury, R., Sturiano, V., Korts, D., Jackson, G., & Cohen, M.
(1982). Alcoholism as a risk factor in methadone maintenance. A ran-
domized controlled trial. American Journal of Medicine, 73, 631 – 636.
Stimmel, B., Vernace, S., & Tobias, H. (1972). Hepatic dysfunction in
heroin addicts. The role of alcohol. Journal of the American Medical
Association, 222, 811 – 812.
Strain, E. C., Stitzer, M., Liebson, I., & Bigelow, G. (1996). Buprenorphine
versus methadone in the treatment of opioid dependence: Self-reports,
urinalysis, and Addiction Severity Index. Journal of Clinical Psycho-
pharmacology, 16, 58 – 67.
Strang, J., Marsden, J., Cummins, M., Farrell, M., Finch, E., Gossop, M.,
et al. (2000). Randomized trial of supervised injectable versus oral
methadone maintenance: Report of feasibility and 6-month outcome.
Addiction, 95, 1631 – 1645.
Volpicelli, J. R., Alterman, A. I., Hayashida, M., & O’Brien, C. P. (1992).
Naltrexone in the treatment of alcohol dependence. Archives of General
Psychiatry, 49, 876 – 880.