Common Misunderstandings

Much of the uneasiness about methadone stems from the idea that it is ''just substituting one addicting drug for another.'' Indeed, this is technically correct; methadone treatment is drug-replacement therapy in which a long-acting, orally administered preparation is substituted for a short-acting opioid that is used intravenously. The long-acting (24 to 36 hours) effect of preventing withdrawal allows most patients to receive a dose and function in a stable manner, without the four-hour cycles of euphoria and withdrawal that characterize heroin use. The objection that methadone is ''addicting'' reflects the recognition that the medication is dependence-producing. Addiction treat ment professionals increasingly distinguish between physical dependence and addiction, the latter being characterized by behavior that is compulsive, out of control, and persists despite adverse consequences. Chronic-pain patients will develop physical dependence though their overall functioning is improved. Appropriate prescribing of benzodiazepines for patients with anxiety disorders is another example of another dependence-producing drug used beneficially for thousands of patients. Although physical dependence is a factor to be considered, addiction specialists increasingly assess the extent to which the person s functioning and quality of life are improved or impaired in order to determine whether physical dependence is an acceptable consequence of medication use.

Another point of discord is the belief that ''methadone keeps you high,'' a notion that reflects misunderstanding about the effects of a properly adjusted dose. Once stabilized, most patients experience little or no subjective effects; heroin addicts will readily state that they seek methadone to avoid becoming sick (prevent withdrawal effects), not to get high. When the patient's dose is being stabilized, he or she may experience some subjective effects, but the wide therapeutic window allows for dose adjustment between the points of craving and somnolence. Dose adjustment may take some weeks and may be disrupted by a variety of medical and lifestyle factors, but once achieved the patient should function normally. There is ample scientific evidence that the long-term administration of methadone results in no physical or psychological impairment of any kind that can be perceived by the patient, observed by a physician, or detected by a scientist. More specifically, there is no impairment of balance, coordination, mental abilities, eyehand coordination, depth perception, or psychomotor functioning. Recently, advocacy efforts have been successful on behalf of patients identified through workplace drug testing and threatened with negative consequences. It is anticipated that the Americans with Disabilities Act will further protect patients against such forms of discrimination.

A third point of resistance, objection to long-term or even life-long maintenance, is better addressed following the presentation of some basic information about opioid addiction and the nature of treatment.

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