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Methadone as a treatment for Addiction: All you ever wanted to know

Methadone is a synthetic opioid with potent analgesic effects. Although it is associated commonly with the treatment of opioid addiction, it may be prescribed for analgesia for various pain conditions. It may be an appropriate replacement for morphine, when side effects limit dosage increases. Methadone toxicity is not always apparent in the first few days after initiating therapy and so careful follow up of all patients is mandatory. Any other medications that the individual is taking may interfere with methadone and hence careful dosing is required. Methadone treatment for pain is a lot cheaper than other long acting morphine formulations. Of all the narcotics, Methadone is the most monitored and regulated prescription medication in North America. However, even though it has been shown to be effective in the treatment of morphine addiction, less than 20% of addicts are currently in treatment. With methadone treatment for addiction, the opioid addicts take regular doses of methadone to decrease the withdrawal and cravings that are associated with opioids. It is one of the most successful treatments for heroin addiction. The treatment is also highly cost effective, costing about $5000 per patient/per year, compared to nearly 25,000$ to look after a patient with AIDs.

Methadone Classification

Methadone is classified as a schedule II of the Controlled Substances Act. Initially, its use was limited to "detoxification treatment” or "maintenance treatment” within U.S. Food and Drug Administration-approved narcotic addiction programs. Because of its potency as a pain killer, the DEA has allowed physicians to prescribe it for pain control. However, most states require that a physician document in the chart that methadone is being prescribed for pain control and not treatment of drug addiction. Many hospitals, however, do not have methadone supplies in their pharmacies. All physicians with appropriate Drug Enforcement Agency registration may prescribe methadone for analgesia.

Methadone Prescription Difficulties

Methadone prescriptions for the treatment of drug addiction are not easily available. The prescriptive authority by physicians is highly controlled and monitored. Only a few selected registered physicians have the ability to prescribe the drug and physicians have to make a special application to the FDA and the Drug Enforcement Agency. The Department of Health & Human Services and the FDA also decide dosage regimens and how, and under what circumstances, methadone maintenance may be used to treat opiate addiction. Most methadone clinics must obtain an extra license and comply with a rigid set of both federal and state regulations. All this has made it difficult for opioid addicts to get methadone. Although there are over 700 active methadone clinics in the Nation, many states don’t allow methadone clinics, forcing some patients to drive across the State each day to get their required daily dosage. Clinics in states that do allow methadone for addiction treatment, often have strict morning hours that make it difficult for patients to stick to the regimen.

Indications

Methadone has been studied as a therapy for cancer pain and other chronic pain states. It is an appropriate replacement opioid when pain remains poorly controlled or when side effects of other opioids limit dosage escalation. Available data suggest that methadone is effective in relieving cancer pain and has a similar analgesic efficacy and side effect profile to morphine.

Methadone Dosing

Methadone has a long half life of up to 40-60hrs permitting the administration only once a day in opioid detoxification and maintenance programs. It also has the ability to diminish pain, but requires multiple dosing. The most common mode of delivery at a methadone clinic is in an oral solution. Methadone can be administered both orally and via injection. When administered for pain control, the onset of analgesia is approximately three to six hours when methadone therapy is initiated, and this duration typically extends to eight to 12 hours with daily dosing. When methadone is administered for drug addiction, its slower onset of action and long half life helps in decreasing the incidence of withdrawal symptoms. In the outpatient setting, methadone dose is slowly increased over 5-7 days, depending on the patient's response. In some opioid tolerant patients, higher doses of methadone may be required over a shorter time. During the initial treatment period, patient progress is continually monitored by the patient, family members, home health nurses, or social workers. Patients should be informed that dose adjustments may be necessary to achieve optimum pain control. In all patients continuous monitoring is required to ensure that withdrawal to opioids is not occurring. The dose can be safely increased in small increments while the patient is in hospital. Frequently, consultation with a pain specialist may help to make the transition to high doses simpler and easier.

Side effects

Side effects associated with methadone include pruritus, nausea, constipation, confusion, sedation, and respiratory depression. Excess sweating and flushing are common with oral methadone dosing. Caution should be taken with initiation of therapy and dosage increases because severe toxicities may not become apparent for two to five days. Side effects such as sedation and respiratory depression are increased when methadone is combined with alcohol or other CNS depressants. In the last decade, there have been numerous reports of methadone related deaths in North America. Methadone can cause slow or shallow breathing and dangerous changes in heart beat that may not be felt by the patient. Emergency room data from US hospitals reveal that more than 80% of these deaths were listed as accidental- and in most cases the death were due to a combination of illicit and other prescribed medications (mainly valium). Like heroin, tolerance and dependence usually develops with repeated doses of methadone. Tolerance to the different physiological effects of methadone varies in individuals. Most individuals develop tolerance to analgesia first and this occurs during the first few weeks of use. Tolerance to respiratory depression, sedation, and nausea also occurs but the time period is variable. Like morphine, methadone does not cause any tolerance to constipation. Like all drugs, methadone is also abused. The abuse of methadone is typically done by the family and friends of the addict. Methadone is also available on the streets but its purity remains questionable. To increase profits, most manufacturers of the illicit methadone add other chemicals to increase the profits.

Methadone for Addiction

Methadone is the gold standard treatment for individuals addicted to the opioid narcotics and has been used widely for the past 4 decades. The treatment of addiction is usually done as an outpatient. The initial starting dose is about 30 mg per day and increased by 10 mg per day until the addict feels more comfortable and has minimal withdrawal symptoms. Some clinics may admit the patient during the induction phase until the patient is stable. Once the cravings have stopped, the individual is discharged and followed closely. Not only does methadone treat addiction it also reduces the morbidity associated with the use of morphine and heroin. Individuals who use these narcotics always share needles and many have acquired HIV in the past. With methadone treatment, it has been observed that the HIV infections have significantly decreased. A point for all addicts- methadone is not the treatment to prevent HIV- safe sex must be practiced simultaneously. More data obtained from the past 2 decades reveal that most heroin addicts have a hard time coming off methadone. Today, there is still some controversy as to the treatment schedule and the duration of methadone treatment and each clinic has its own version of treating addiction. Some believe that methadone treatment is indefinite and others believe that we have sacrificed addiction to one bad drug (heroin) with another good drug like methadone- and ultimately methadone also becomes the bad drug. When methadone is taken orally, it suppresses the symptoms of morphine withdrawal for about 24-36 hours. It has only been shown to be effective in the treatment of opioid type drugs and has no effect on prescription drug addiction. Methadone reduces the cravings for morphine and because it stays in the body for long periods, the euphoric effects and the depressive episodes are not seen. In the end the individual becomes dependent to methadone but is freed from the uncontrolled and compulsive urges that are very typical of heroin. Many individuals are able to live a well balanced life and may even become useful members of society. Unlike heroin, methadone does not impair cognitive functions. It has no adverse effects on mental functions, intelligence or capability. Nor is it sedating or intoxicating, and does not interfere with ordinary activities such as driving a car or operating machinery. However, individuals are able to sense pain and experience all the normal emotional reactions. Most importantly, methadone decreases the craving associated with opiate addiction. For methadone patients, the heroin on the streets is unable to generate its euphoric effects anymore, thus making them less prone to using the illicit drug. For most individuals, methadone withdrawal is usually done over a few years and in many cases does not work as the individual has become physically dependent to the drug.

Chronic pain

Many physicians do not even know that methadone is a useful drug in the treatment of pain. However, the drug is an excellent pain killer and is frequently used to treat chronic pain. The drug is longer lasting than morphine and the pain relief is excellent. Unlike other narcotics, it does not have to be taken 3-5 times a day. Another factor that has made methadone a popular pain relief drug is that it is much cheaper than morphine. However, many physicians do not know much about methadone and are afraid to prescribe it.

Cost

Methadone offers a cost savings over standard morphine preparations when used to treat pain. Legislation is being considered to reduce or even eliminate some regulations on methadone providers to make treatment more widely available.

Future

Methadone is a prescription medication produced by licensed and approved pharmaceutical companies using quality control standards. In most US states, its use is controlled and all individuals are carefully monitored. The government does not take too kindly to anyone who abuses Federal Chemicals. Under a physician's supervision, it is administered orally on a daily basis with strict program conditions and guidelines. The recent availability of buprenorphine for opioid addiction treatment has brought more optimism to the field of drug addiction. Like methadone, buprenorphine is a replacement therapy. It is easier to withdraw from than methadone, however. And the risk of buprenorphine being diverted illegally is much less than for methadone; if it is injected by a would-be abuser; it causes withdrawal symptoms and not a "high."
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