How Does Methadone Treatment Work

Most addiction specialists agree that addictive disorders are complex phenomena involving the interaction of biologic, psychosocial, and cultural variables, all of which need to be considered to make treatment effective. Dole and Nyswander, who pioneered the use of methadone, held the view that there was something unique about opioid addiction that made it difficult for patients to remain drug-free. Although originally intended as a long-term treatment for a metabolic defect, many initially hoped that methadone could be used to transition heroin addicts to a drug-free lifestyle and then be discontinued. Research in the subsequent 30 years indicates that less than 20 percent will be able to discontinue methadone and remain drug-free. As his thinking evolved, Dole (1988) postulated that a receptor system dysfunction resulting from chronic use leads to permanent alterations which we do not currently know how to reverse. New brain imaging technology holds the promise of better understanding and, eventually, improved intervention, but in the interim it appears that meth-adone is corrective although not curative for the severely addicted person. Two important questions for future research are whether a preexisting condition enhances the vulnerability of some patients more than others, and whether long-term addicts can ever recover normal functioning without maintenance therapy.

For now, studies indicate that methadone is a benign drug which exhibits stability of receptor occupation and thus permits interacting systems to function normally. One example of this is the normalization of hormone cycles and the return of regular menstrual cycles in women. This distinguishes it from heroin, a short-acting narcotic producing rapid changes that make a stable state of adaptation impossible. Although tolerance develops to most effects, it is fortunate that even long-term use (30 years or more) does not produce tolerance to the reduced craving, or to the narcotic withdrawal prevention effect.

The desired response to methadone depends on maintenance of a stable blood level at all times. Appropriate doses usually keep the patient in the therapeutic range of 150 to 600 ng per mL in the blood and produce the stable state so important for rehabilitation. What is referred to as a ''rush'' or

"high" is the result of rapidly changing blood levels; thus, once therapeutic levels are achieved and maintained, the patient experiences little subjective effect.

Unfortunately, negative attitudes toward methadone have historically played a significant role in dosing practices, manifested in dose ceilings imposed by state or local regulations without regard to medical criteria. Such policies placed value on giving as little of the drug as possible (versus the therapeutic level needed to accomplish the goal), influenced in part by the belief (unsubstantiated) that lower doses would make it easier to discontinue methadone. It was common to have dose ceilings of 40 mg per day. It is now well established that this is inadequate to maintain the necessary plasma concentrations to be effective; the effective range is between 60 and 120 mg per day for most patients, with some needing less than 60 and others considerably more than 120 mg. The higher and more adequate doses are strikingly well correlated with reductions in illicit drug use and improved retention in treatment (GAO, 1990; Caplehorn & Bell, 1991). How painfully ironic to recall that patients on low doses who complained that ''my dose isn't holding me'' were often dismissed with the assertion that they were ''merely engaging in drug-seeking behavior.'' And when the distressed patient then supplemented the methadone dose with heroin, it was concluded either that the patient was poorly motivated, or the treatment was ineffective. Studies by D'Aunno and Vaughan (1992) show that more than 50 percent of patients nationwide receive doses that are inadequate to prevent continued illicit narcotic use, indicating both poor physician training and inappropriate involvement by regulatory agencies and legislative policies.

Initial hopes to use methadone as a drug to transition patients to a medication-free life style have proven unrealistic. Studies indicate that although short-term abstinence is common, relapse is the norm for 80 percent or more (McLellan et al. 1983; Ball & Ross, 1991). Clinicians who have worked with this population over the long term believe that although lifestyle changes are essential to successfully discontinuing methadone, such changes in conjunction with high motivation will still be insufficient for most; neurobiological factors remain a deciding factor. Because the current treatment system, overburdened by regulations and inappropriate expectations, is dehumanizing

Vincent Tobin, director of this methadone treatment center in Greenfield, Massachusetts, and registered nurse Mary Ann Gendreau await clinic clients, April 13, 2000. (AP Photo/Craig Line)

for many, programs usually make efforts to assist the patient who wishes to taper off methadone. However, many of these programs attempt to create an environment in which the patient is encouraged to succeed, but also to resume methadone treatment promptly once relapse or the likelihood of it occurs.

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