Realigning the Australian community expectations of Methadone Maintenance Programs

By Darren Hamburger

Against much opposition at the time, Pioneer Dr Stella Dalton introduced the Methadone Maintenance Program (MMP) as a treatment modality for Opioid dependence in New South Wales Australia.¹¹ Working under the supervision of Dr. Dalton for 5 years provided me with a great deal of understanding regarding the many facets encompassing addiction. It is with this clinical experience I write this article to address an ever growing observation regarding the disparity of opinions with respect to Methadone within the broader Australian community.

In order to increase awareness surrounding Methadone and it's intended function, I will discuss topics such as what is Methadone, why Methadone is prescribed, what are the goals of Methadone and of course why is Methadone used as a treatment modality. Another important issue incorporated within this article are some negative connotations which have developed over time in Australia and are evoked at the very mention of this medication.

Attempting to explain the various reasons behind why addiction occurs, exceeds the scope of this article and is better discussed in depth within a separate article. Thus suffice to say their are a multitude of reasons be it circumstantial, biological, conscious or unconscious which explain how a person may become dependent upon a substance. While the individual may present as having a drug of choice, it is my opinion in Australia poly substance use or even substance use in combination with other forms of addictions i.e gambling reigns superior in presenting addiction case frequency if compared to an individual who only consumes a single substance.

Prior Opioid Treatment Failures

Methadone is a medication which is most frequently prescribed as a treatment for Opioid dependence, however Methadone has also been known to be prescribed for pain management.^7,14 In her book the drug addict as a patient, on page 25 Marie Nyswander mentioned Methadone could be traced back since the WWII era ² in Germany.¹⁵ However It wasn't till mid 1960's that Dole & Nsywander had identified the merits of Methadone to combat Opioid addiction.¹⁶ Prior to Methadone being used as an Opioid dependence treatment, Morphine & Heroin were used in a controlled manner in an attempt to appease the Opioid dependency. However the results failed purely because clients were unable to be stabilised due to the relatively short half life of the two drugs.¹ Dole reported The failure of previous attempts to maintain addicts on morphine soon became apparent: the patients could not be stabilized on the drug. Despite frequent injections, their condition fluctuated between somnolence and agitation throughout the day, with tolerance increasing over consecutive days to the point that they were almost continuously agitated even when receiving huge doses of morphine.¹⁰

Methadone and the Methadone Maintenance Program (MMP)

Methadone is a full agonist synthetic Opioid⁷ which has a high affinity and activation for mμ receptors which is longer acting if compared to other Opioid's such as Heroin. Client's who are undertaking Methadone as a treatment for Opioid dependence are said to be participating on the Methadone Maintenance Program (MMP). The (MMP) generally consists of the participant, a prescriber, Methadone, a dosing point and ongoing progress review. Treatment may also be supported with psycho-social supports I.e counselling, employment, accommodation, health and referral to other specialised services. The treatment phases of the (MMP) generally consist of evaluation, stabilisation and maintenance. The fourth optional phase we can call termination which sees the patient having their methadone titrated down in order to terminate the treatment regime. The reason behind I placed the fourth phase as an option is because (MMP) termination is dependant upon the combined view of the professional and client. There are some within the community who suggest Methadone should be maintained, while others may push for an exit date. I on the other hand have a variable view which one could say is an estimated forward looking projection of potential consequences based upon the clients lived history i.e how likely is the client going to relapse, social and other supports currently available, emotional status at the time, overdose risks, the likelihood the client may return to jail etc. The client's relapse history and the consequences of such relapses which caused a disruptive and dysfunctional lifestyle must always be considered and discussed with the client prior to the decision to decrease or terminate the (MMP). When chosen for the purpose of (MMP), In Australia Methadone is most likely to be dosed in suspension liquid form, however historically speaking Methadone is also known to have been dispensed via tablets or via injection in different countries. Clients who are participating on the (MMP) in Australia will typically pick up there dose at specified dosing locations such as public clinics or for those private chemists who have chosen to dispense methadone.

The client indicates their readiness to participate on the (MMP) when they attend an assessment interview by an appropriate health professional AKA a ‘prescriber’. Once deemed appropriate, it is then up to the treating health professional to identify health risks, client reliability, appropriate prescribed dose, risks of dose diversion, risks of other medication interactions and when the time is right to receive take away dosing. A client who has been assessed and deemed clinically stable is able to receive several doses to take home AKA takeaways which removes the need for the client to attend the clinic dosing point on a daily basis and allows the client to transition to a normalised lifestyle with as little interference as possible. While dose diversion or misuse has been known to occur, takeaway doses also has its merits. Obviously the need to attend a clinic on a daily basis can impact upon other functional areas of life i.e. employment or other aspects of life whereby others would normally take for granted such as going on a holiday at the spur of the moment. Conversely the attendance of a daily clinic dosing does allow the client to be supervised thus acts to prevent medication diversion, in addition to monitoring the client's presentation and current health status for early intervention purposes.

The Goal of Methadone

Addiction has many faces, each with a different set of problems and while Methadone seeks to address some of the issues, it does not and cannot cure all. Vincent Dole had concluded that Methadone Treatment, therefore, is corrective but not curative for severely addicted persons,¹ which is a statement I tend to agree with. Dole also placed emphasis on (MMP) success would only be attained if treatment is prescribed under favourable conditions.⁸ Therefore I feel it prudent for me to set the underlying premise of this article by stating Methadone and it's subsidiaries i.e Buprenorphine, Naltrexone, Subutex and the like are not a silver bullet to ceasing the all encompassing issue of addiction. However with regards to ceasing Opioid use only, Methadone does very well in halting continued Opioid use once on an appropriate dose has been reached and the client has been stabilised. Dole suggested As a general rule, 60-80mg of oral d-methadone hydrochloride a day (reached by gradual increase over four to six weeks) is adequate and not excessive. Although in exceptional cases substantially higher doses may be needed.¹ However via discussions with Dr. Dalton during my internship years, Stella had believed blockade was most effective from around 80mg and clients depending of their need would increase their dose to make the client feel comfortable and cease relapsing. We can view the term ‘ Blockade ’ as a descriptor which indicates the opioid receptors are at a saturation point, thus the patient no longer experiences the desire to search for Opioids because the client has reached a functional equilibrium whereby the europhoric effects of Opioid's is blocked.¹² The increasing to higher dosing is not a new strategy in Opioid dependence treatment, whereby Dole had also recognised that higher dosing of Methadone may be necessary and held the view the prudent policy is give enough medicine to ensure success .¹

Understanding Opioid Addiction

The general public's lack of understanding regarding the finer aspects of addiction or discern the differences between Opioid and other non Opioid substance dependance, is likely to be the sole reason the general pubic may find themselves becoming confused and easily swept away by media reports which may obfuscate the true differences between dependence, treatments and the various illicit substances used by dependant individuals. When we think of Methadone, we need to think Opioid! Nothing more and nothing less and when we understand the (MMP) only treatment focus is on Opioids,⁹ we very quickly come to realise why people who are on a (MMP) may also use THC, a variety of pills, Alcohol addiction, Speed, Methyl-Amphetamine, or even Cocaine. Of specific relevance here is all of these substances mentioned are outside of the realm of Opioid's and will not be actively treated via Methadone because they are an entirely different beast altogether.

Methadone Discovery

In a metabolic ward of the Rockefeller University Hospital in 1964, the first Methadone research trials for treating Opioid dependence started with 6 clients. With positive results unseen by any other treatment modality at the time, Dole & Nyswander identified clients taking Methadone remained stable, ceased seeking Opioid's altogether and were able to lead functional lives once again. Thus from this point in time onward Dole & Nyswander were seen to have been the founders who championed Methadone as an Opioid dependence treatment. When describing their own observations of their clients starting Methadone dosing, Dole stated A remarkably different result was seen when in the course of the scheduled testing, methadone was administered. The fluctuation in clinical state became less and then disappeared. Doses became stable. The patients seems normal. Most remarkably, their interests shifted from the usual obsessive preoccupation with timing and dose of narcotic to more ordinary topics. (Dole, Nyswander & Kreek, 1996).¹

Metabolic disease verses Criminality

Dole & Nyswander had theorised the damaged receptor theory thus Dole viewed Compulsive use of narcotics stems from receptor dysfunction¹ Dole believed Narcotic addiction was the result of a Metabolic disease and did not simply amount to criminal behaviours and personality disorder. Therefore in light of Dole's beliefs, he suggested there was a difference between an individual involved with criminal behaviour prior to narcotic dependence compared to those persons who exhibit criminal behaviour only once narcotic dependence had occurred. Thus (MMP) would only assist with criminality as a result of Narcotic dependence because criminality prior to addiction is likely to be an innate beahviour and addiction had superficially attached to the innate criminal behaviours giving the impression the behaviours were as a result of addiction.

Primary and Secondary Benefits

The aim of methadone is ultimately intertwined with primary and secondary potential benefits. The primary benefit is ceasing narcotic use while the secondary benefits are attributed to positive and functional lifestyle change. Through the efforts of past research, Dole & Nyswander identified participants on the (MMP) had made significant improvement in wellness notably no desire to search for Heroin, a reduction in crime, clients being job ready and a greater focus on participating in life without the need for ongoing search for drug use.^1,5,10 Dole suggested There should be no ambiguity about the primary goal of methadone maintenance program, Stopping the use of heroin and other illicit narcotics.¹³ Caplehorn & Batey (1992) had also made reference to the purpose of Methadone by quoting an extract from the policies and procedures section in the Directorate of the drug offensive report 1989 The principle aim of methadone treatment programs is to assist Opioid dependent persons improve their health and social functioning and alleviate the adverse social consequences of their drug use by reducing and eliminating their illicit Opioid use.¹¹ Moreover, Dole outlined Methadone was not indented to address non Narcotic conditions → Alcoholism, non-narcotic-drug abuse, psychopathic behaviour, and delinquency are not stopped by methadone. ¹³

Medication Diversion

To divert ones medication is to use the medication in a manner that is not prescribed. In the case of Methadone diversion the act is not to take the medications as prescribed and may be attributed to the following

• The sale of Methadone for money
• The trade of Methadone for another items or substances
• The intent to use an Opioid such as Heroin to feel the rapid onset of euphoric effects not experienced with Methadone
• To take more Methadone than prescribed i.e double dosing to obtain an intoxicating effect
• To deliberately misuse the intended administration route I.e I.V instead of drinking the Methadone
• The hording of Methadone for later use or other transactions

Methadone dose diversion however comes with certain risks such as overdose if combined with other CNS depressant drugs, overdose as a result of excessive Methadone intake, damage to circulatory system and other organs in the case of IV administration, hording doses maybe found by others / or accidentally consumed, inappropriate use of Methadone may result in cognitive impaired injury or death when operating machinery or driving a vehicle especially in narcotic naive persons.

Negative Connotations in the Community

The final point I wish to briefly discuss in this paper are some of the more commonly attributed negative connotations attached to Methadone and how these may have emerged.

From time to time community members may pose the question why are people on methadone and still not job ready? Merely ceasing addiction does not automatically mean any individual is ready for work. While some who have stablised on Methadone are able to transition into employment, others unfortunately may still grapple with the underlying issues of addiction whereby the community may falsely attribute Methadone had not helped or causing the unemployment.

Members of the pubic may be inclined to lay blame upon Methadone being the sole cause of the individual being unemployed, while not being aware of the other factors which pose difficulty for a person to find and maintain employment. Some factors such as the individual may be lacking in employment skills or has a chronic unemployment history, experiences literacy and numeracy challenges, has a mental health condition, continued poly substance abuse or have unstable housing environment to reside in. Other aspects commonly overlooked which may act to inhibit employment opportunities are tattoos, lack of presentation skills, criminal histories, dysfunctional lifestyle, lack of employment seeking skills and of course age without employment history. While some may wish to deomonise Methadone and cast blame for unemployment are doing so due to there own ignorance regarding addiction while disregarding the fact Methadone is only but one part of a larger puzzle with respect to what skills are required to seek, obtain and maintain employment.

With respect to Methadone and the capacity for employment, there are various considerations which should be taken into account. For example: is the person on a stable v fluctuating Methadone dose, are additional medications being prescribed affecting cognitive ability while also prescribed Methadone, active poly drug use which magnify intoxication, dose diversion & method of picking up Methadone and of course the nature of employment which may or may not legally permit an employment function while being prescribed medications.

From time to time people with influence without a clinical understanding of the treatment of addiction will assume it is their duty to get a person off a (MMP) because it does not sit comfortably with their own views. Thus, instead of seeking to further understand the treatment phase of addiction, will attempt to push for the person to end the (MMP). Such possibilities I raise here are employment agencies, employers, relationships, family, NGO organisation who may be against (MMP) the list goes on. It should go without saying, only a trained professional with a clear understanding of (MMP) and addiction should be the individual to discuss at what point should a client reduce, increase, stay on or cease taking Methadone. I do believe it is imperative to consider the repercussions should the client choose to cease the (MMP) which is something I explore every time with a client who I am consulting with wishes to ceases to terminate (MMP).

I am a firm believer the client should ultimately be the person to chose their own future because ultimately the decision they make they will have to live with the consequences. In regards to client's on the (MMP), the single most enduring feature to overcoming an addiction is the desire to actively participate in their life and take control and own the responsibility for the decisions they make. Therefore if a client who wishes to stay on a (MMP) and is not using Opioids and is functionally appropriately within the community, then who am I or anyone else to tell that person to stop when they have stablised.

The decision to cease (MMP) is not a decision to be taken lightly and many other factors need to be considered than simply stopping the (MMP). Perhaps the client has recognised each time they have ceased the (MMP) they relapsed, perhaps the client has a chronic history of relapse and in the past engaged in criminal behaviour and served time in jail which tends to be an endless cycle. All decisions have serious consequences, especially if a persons history dictates rapid onset of drug use in small time frames. Ceasing methadone is not without it's complications as it has also been shown clients ceasing methadone are especially at greater risk of overdose and death due to reduced tolerance of opioids.^4,6

Liquid hand cuffs is a term typically used by consumers of Methadone which mostly relate to the clients movement freedoms being bound to the location of picking up the Methadone. Although the phrase is also attributed to feelings of loss of control in the clients life as they are depending on a medication for stabiliaation and dependent upon the prescribers willingness to provide the medication. A client on Methadone is unable to spontaneously leave for a long holiday without reorganising when and where the methadone will be provided. While it is possible to dose at different locations for a holiday, this would generally require the client to plan ahead and to arrange the dosing locations at the holiday destinations. Takeaway dosing in NSW has it's restrictions which generally do not allow for a long period of holidays i.e 6 to 8 weeks of consecutive daily dosing and then there is the possible difficulties encountered with customs and other countries laws. Some clients from Jail have expressed the idea methadone is used as a modality to exert power in order to control them.

There are times a consumer of methadone may present excessively intoxicated and the person may attribute their presentation as just having Methadone. When anyone presents with words slurring, drowsiness, ataxia and poor memory concentration the general public are not oblivious to observing the client being heavily intoxicated. Unfortunately because Methadone is accused of causing the intoxicated appearance, a poor reputation develops further supporting the communities negative connotation that Methadone is bad, it doesn't help, it's just another hit or look what it is doing to you!. The reality however is vastly different whereby the blaming of the methadone is more of a function of an active addiction. An attempt to deceive the other person in order to hide drug use.

However if a client is on a stable dose of Methadone, methadone itself will not cause a client to appear excessively intoxicated due to neuro-adaptation. I used the word stable which should be clarified to be on the same dose for three months or more which does not see the dose of Methadone being reduced or increased in the preceding three month period and is in the absence of other medications interacting with the Methadone. This begs the question, if a client is on a stable dose and presents extremely intoxicated and drowsy why is this happening? The answer must thus default to the client is likely to be using other substances be it through other prescribed medications or the client is abusing other substances which interact with the Methadone i.e Alcohol or illicit substances or possibly injecting Methadone. In the event the client is presenting very drowsy and the drug analysis is proven to be negative for other substances, one must consider the client may be either double dosing or injecting Street Methadone or their takeaways.

When a client is noted to be on a stable dose for some time and is presenting drowsy claiming It's the methadone. I have found more times than none, the client will fess to ongoing use of substances in combination to Methadone when asked, providing the therapeutic relationship is strong. To a lesser extent ownership of misusing Methadone i.e via IV use or double dosing should also be expected because the client may fear information will go back to the prescriber. Conversely, I have found historical reports of methadone misuse tends to be more forthcoming when asked during clinical history taking.

While the public may hold the view and assume Methadone is just another high, the reality is very different if compared to other narcotics generally used i.e Heroin. Narcotics like Heroin once used will give the consumer a dramatic mind state change thus the hit is felt very quickly if injected, and a little longer if smoked. Conversely with Methadone, any affect experienced is slower and over a longer duration¹⁵ which avoids the sudden Hit sensation others would tend to expect when abusing an Opioid.

There comes a time in a drug users life a decision is required and certain decisions may not work fully in their favor. Sometimes life is a matter of choosing the best of the worst decisions. A consumer of Narcotics who is dependent will more times than not experience significant lifestyle decline which sometimes leads to irreversible consequences for example death, disease, unplanned pregnancies or even criminal histories which interfere with future employment. Other aspects which may also be attributed to ongoing dependence to narcotics are homelessness, estrangement from family, friends and partners, impacts to mental health and of course financial difficulties just to name a few. While others may see taking Methadone as not being the desired choice, the benefits of stability far outweigh the negatives regardless. Therefore the assumption Methadone is worse must be weighed against all other factors of addiction. In a perfect world a person should not need Methadone or Narcotics or any other substances for that matter, however we do need to take the perfect world glasses off and replace them with reality glasses. The reality is more people than not who are dependant to narcotics will benefit taking Methadone and not everyone can abstain from using Narcotics.

Conclusion

Over the many years working with clients of addiction who participate on the (MMP), I have witnessed various people in the community express negative comments regarding Methadone. Broadly speaking, I have found the general public have difficulty understanding addiction and tend to pigeonhole all drug users together while at the same time hold high expectations of such people who are at the time not functional within society. This is even more evident when the community may lay claim methadone does not work to stop Drug use because they fail to understand methadone function is to act on Opioids not other non-Opioid substances. Sadly, the lack of community understanding upon the benefits of Methadone tend to place unwarranted pressure for those who are benefiting on the (MMP) to prematurely terminate, while either ignoring or dismissing any benefit to stability gained.

This article attempted to broaden the readers awareness of methadone, its intended function within the treatment of Opioid dependence in addition to discussing some negative perceptions and how these perceptions may have evolved.

I am neither for or against Methadone, however methadone is one treatment modality that I have seen work for clients, and it is proven to work when used correctly. However I strongly feel it is up to the client to decide which treatment modality they choose to take, my role as the psychologist is to educate, support and help the client towards abstinence regardless how it is achieved.

References

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