Program Goals/Target Population
Methadone maintenance treatment (MMT) is a medication-assisted treatment for individuals with opioid dependence. Methadone is a long-acting synthetic opioid analgesic that works as a pharmacologic intervention for patients in drug treatment and detoxification programs. MMT helps opioid-addicted patients alleviate withdrawal symptoms, reduce opiate cravings, and bring about a biochemical balance in the body in order to reduce the illicit use of opioids.
Opioids, such as heroin or morphine, cause a release of excess dopamine in the body. Users become dependent on the drug because they need opiates to continuously occupy the opioid receptor in the brain. Methadone works by occupying this receptor and blocking the high that usually comes from illicit opioid drug use. This reduces the need and desire for users to seek and abuse opioids and diminishes the disruptive and uncontrolled behavior often associated with addiction. Subsequently, this allows patients to participate in normative activities, such as drug treatment programs or therapies.
Methadone can suppress narcotic withdrawal symptoms for 24 to 36 hours for patients. Single oral doses are administered daily under observation at a licensed clinic. Patients may receive take-home doses for a day that the clinic is closed. Patients may also become eligible for unsupervised take-home doses after some time under monitored treatment.
Dosage is determined by several factors related to the patient, such as opioid tolerance level, history of opioid use, age, and current medical status. During detoxification, an initial dose of 20–30 milligrams (mg) is usually prescribed to suppress withdrawal symptoms. For MMT, doses of 80–120 mg per day are generally sufficient to prevent opioid symptoms for 24 hours, reduce cravings, and block the euphoric effects of opioids. The amount of time in MMT will also vary by patient. In general, MMT takes a minimum of 12 months, but some patients may require continuous treatment that lasts over a period of several years.
In addition to administering medication, MMT also involves providing patients with comprehensive rehabilitation services. Services can include group therapy, individual therapy, medical services, and referrals to community-based agencies that can assist with health and mental health issues, HIV prevention and intervention services, education, housing, and employment.
MMT is one of the most monitored and regulated medical treatments in the country. Therefore, methadone, when used in the treatment of opioid addiction, can only be dispensed by federally licensed opioid treatment program (OTP). OTPs must be certified by the Substance Abuse and Mental Health Services Administration (or SAMHSA) and registered with the Drug Enforcement Agency (or DEA).
One limitation to MMT is the possibility of patients abusing and overdosing on methadone. The number of methadone-associated deaths has been increasing in the last decade (Center for Substance Abuse Treatment, 2007). Yet part of this problem may be related to the increase in prescription methadone that, in addition to treatment for opioid dependence, can also be used in the treatment of chronic pain (Paulozzi, Budnitz, and Yongi, 2006). OTPs are subject to specific and strict regulations when using methadone to treat opioid-addicted patients. However, when methadone is prescribed to treat chronic pain, it is regulated under Federal and State laws that impose broad requirements for controlled substances in general but whose regulations are not as strict as they are for MMT use. Although it is unclear from the current data available how many methadone-related deaths are associated with MMT or chronic pain treatment, steps are being taken to prevent deaths related to methadone abuse and overdose that include educating practitioners, improving safety, and establishing prescription monitoring programs (GAO, 2009).
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Sees and colleagues (2000) found that treatment group members who received methadone maintenance treatment (MMT) remained in treatment significantly longer than comparison group members who received psychosocially enriched 180-day methadone-assisted (M-–180) detoxification. The median days in treatment for MMT participants were 438.5 days, compared to 174 days for M–180 participants.
There were no significant differences between the groups on opioid use. Illicit opioid use rates were greater than 50 percent for both groups at all follow-up periods. When examining another index of heroin use (days of heroin use in the previous month, as reported on the Addiction Severity Index, or ASI), the results showed heroin use for both groups significantly decreased from the baseline, but the decrease was greater in the MMT group during the last 6 months of treatment.
HIV Risk Behaviors
The level of HIV drug-risk behaviors reported by MMT participants was significantly lower than those reported by M–180 participants; however, there were no significant differences on measures of sex-risk behaviors. The analysis also showed that there was a significant group-by-assessment interaction on reported injection of heroin, meaning the MMT group had significantly less needle use during months 6 through 12.
There were no significant differences between groups on measures of psychiatric problem areas, family functioning, employment, or legal status.
At each assessment, only 30 percent to 50 percent of study participants in both groups were abstinent from cocaine. Although M–180 participants had significantly lower cocaine use rates at certain follow-up periods (month 4–7 and 9–12), the difference between the groups was confounded by the fact that cocaine users were more likely to drop out of M–180 treatment. After additional analysis, the significant difference in cocaine use between groups disappeared, suggesting the initial difference was observed because of the higher probability of cocaine users dropping out of M–180 treatment.
There were no significant differences between the groups on measures of alcohol use.
Gruber and colleagues (2008) found that there were a number of significant differences found when comparing the 21-day methadone detoxification group to the 6-month methadone maintenance with minimal counseling (MM minimal) and to the methadone maintenance with standard counseling (MM standard). However, there were no significant differences on any outcome measures between the MM minimal and MM standard groups.
There were no significant differences between the three groups in retention rates.
At baseline, all three groups urinalyses were 87.5 percent to 100 percent opiate positive, and their self-reported heroin use averaged 18–19 days of the previous month. During months 1–6, 78 percent to 96 percent of the 21-day methadone detoxification group had opiate-positive test results, and they reported heroin use an average of 15.5–18.4 days in each follow-up month. In contrast, the MM minimal group had a significantly greater reduction from baseline in opiate-positive urine tests (65 percent to 85 percent of participants had positive results) and self-reported heroin use (an average of 5.8–8.1 days per month) during the follow-up periods. The MM standard group also had significantly greater reduction in opiate-positive urine tests (59 percent to 77 percent of participants tested positive) and self-reported heroin use (an average of 4.2–6.1 days per month) compared to the 21-day detoxification group. The comparisons remained significant when the 8.5 month follow-up assessment was included.
Compared to the 21-day detoxification group, the MM minimal group and MM standard group had significantly greater reductions from baseline in self-reported days of alcohol use during months 1–6. The comparisons remained significant when the 8.5 month follow-up assessment was included.
There were no significant differences between the three groups in cocaine-positive urine tests or self-report days of cocaine use during months 1–6 or when the 8.5 month follow-up assessment was included.
There were no significant differences between the three groups in outcome measures from the ASI or the Beck Depression Inventory (or BDI).
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