Chapter 1 - Methadone and other options
From: Methadone Maintenance Treatment: Client Handbook
In this chapter:
- Is methadone maintenance treatment for you?
- The benefits of MMT
- The drawbacks of MMT
- Other treatment options
- Narcotics Anonymous
- Alternative addiction self-help
- Day/evening and residential treatment
- Weighing your options
Is methadone maintenance treatment for you?
If you've been using opioid drugs such as heroin, OxyContin, codeine, Dilaudid, Percocet and others, and you've come to a point where you know you can't go on using, but you can't seem to stop either, methadone maintenance treatment (MMT) may be right for you.
If you're pregnant, and you're using heroin, seek MMT right away. Methadone prevents opioid withdrawal, which can threaten the life of your baby (see Chapter 7).
Users who are HIV or hepatitis C positive are strongly urged to begin methadone treatment immediately. MMT helps to stabilize your health, and it lets you focus on getting the best possible care (see Chapter 4).
You may be ready for MMT if you've been using for a year or more, and you've tried to stop. You've been through withdrawal, you've seen a counsellor, perhaps you've gone through a residential treatment program. If you can't seem to stop using for more than a few hours, days, weeks or months at a time, and you know you want to stop, think about going on MMT.
You're ready for MMT when you're still using and all it's doing for you is keeping you "normal." If there's any high at all, it isn't worth it anymore. You're scared of being sick and all you want is to feel well and be free of the craving that nags you to keep on using. You want to be more in control of your life, your work, your home. You want to feel better about yourself; you want to be able to offer more to the people you care about.
If you think you're ready for MMT, read through this handbook to find out what it is, how it works, what to expect and where to go. Pass this handbook on to your family and friends to help them understand and be able to offer you the support you need.
Treatment programs vary, so be prepared to ask questions. The more you know, the more you'll be in control of getting where you want to go. Help is available.
"I wish I had kept a diary from just before I started methadone, then every time I am having a difficult time, I could re-read my thoughts and know that I do not want to return to that place."
— Adam, 20, on methadone three months
The benefits of MMT
For people who are dependant on opioids, methadone has a number of benefits over other opioids. These are:
- The effects of methadone can last 24 to 36 hours. For most people, as long as you take your one dose a day at the same time every day, you won't get sick with opioid withdrawal.
- You drink your dose of methadone, usually in a mixture with orange juice. Taking an oral dose is much safer than injecting, snorting or smoking.
- Drinking methadone won't get you high, but it can help to keep away the physical drug cravings, or the feeling that you need to get high. Some people experience no cravings at all once they're on methadone. Others may continue to struggle with the "conditioned" cravings, or those that are triggered by something or someone you associate with drug use. The counselling you can get with MMT can help make it easier to cope with cravings.
- When prescribed by a doctor and dispensed by a pharmacist, methadone is legal. The source is reliable and safe, and there's no fear of arrest.
- Methadone is made using strict manufacturing guidelines. The exact potency is known, and it's never cut with unknown substances. You know what you're getting.
- The cost of methadone is less than $10 a day. If you have an Ontario Drug Benefit Card, or are covered by a prescription drug plan at your work, or through a member of your family, methadone costs you nothing. You may also qualify for financial assistance through the Trillium Drug Plan. (For more information on help with the cost, see Chapter 3.)
- Some illicit-drug users participate in a lifestyle that involves crime and other risky activities to support their need for drugs. Methadone replaces this need with a substance that is legal and cheap. Methadone treatment can result in less crime, fewer people in jail and a safer community.
- People on methadone are less likely to use or share needles. If you're not using needles, the risk of becoming infected with HIV or hepatitis C is reduced. And since methadone lets you think straight and use your head, you'll be more likely to practice all you know about safe sex.
- Methadone blocks the euphoric effect of other opioid drugs. For example, if you take a hit of heroin when you're on methadone, you may not feel it. Methadone's opioid-blocking effect can be a benefit because it takes away the main reasons why you might continue to use other opioids. If you can't get high, and you won't get sick if you don't use, why waste your money?
- Going on methadone treatment can put you in touch with people who understand where you're at, and can help you get where you want to go.
- Once you've been on methadone for a while, you should feel more energetic and clear-headed. This lets you focus your life on things like work, school and family.
- Of all treatments for opioid dependence, MMT has the best record for keeping clients off other opioid drugs.
"Methadone worked for me, but I knew what I wanted when I went on it: to live without heroin for life. It did help me to do that. I've been abstinent from all other drugs for nine years.
"If you want methadone to work for you, you've got to make the decision and follow it through. You need will, desire and determination. You need to have a positive attitude, you need to have self-respect.
"My reward has been the chance to enjoy my family, to find employment, to have good health in my mind and body, and to be in control, for once, of my own happiness. I've learned a lot about myself. I'm friendlier and more helpful to others. I love me now, and I love life!"
— Margaret, 41, on methadone 11 years.
The drawbacks of MMT
- Methadone is not a cure for opioid dependence; it is a treatment. For it to work, you've got to want it to work. Success requires motivation and determination.
- Methadone treatment replaces opioids such as heroin, OxyContin and codeine with another opioid, methadone. You are still opioid dependent, and if you miss more than one dose, you will experience flu-like withdrawal symptoms.
- Methadone clients may be branded as "still addicted" by some members of the community. Many people don't understand methadone treatment, even some people who work in the addiction and health professions. Some drug treatment programs and self-help groups like Narcotics Anonymous (NA) are abstinence-based, and may not accept methadone clients. Some doctors and pharmacists are reluctant to work with methadone clients, perhaps fearing they will be pressured to supply prescription drugs. Some employers may not react kindly if they discover that you're a methadone client. It's probably fair to say that most people regard methadone treatment as a positive step, but there will be exceptions, and you should be prepared for that.
- While methadone detox is sometimes used to withdraw opioid users by reducing their opioid dose gradually over a short term, methadone maintenance is a long-term treatment. You can expect to be on it for at least a year or two. Some stay on for as long as 20 years or more. In general, the longer you've been dependent on opioids, the longer you'll likely stay on methadone. Other factors include how long you want to stay on methadone, and how things are with your family, home and work life.
- As it stands now, methadone treatment guidelines say that for the first few months of treatment you have to go to the clinic or pharmacy every day to get your dose. Even after a year of treatment, you still have to go at least once a week. Expect to make a lot of visits to your doctor too.
- You will be asked to produce samples of your urine for drug testing frequently. It's often required that these samples be produced "under observation," meaning someone will be watching you to be sure that the urine is yours, and that you haven't done anything to change it.
- Methadone can have some unpleasant side-effects. These are likely to be more pronounced at the beginning of treatment — during the two- to six-week dose stabilization phase when you may experience withdrawal symptoms. The most frequently reported side-effects include drowsiness and light-headedness, nausea and vomiting, excessive sweating, constipation and change in sex drive. Other complaints include insomnia and agitation, joint pain and swelling, ankle swelling, skin rash, dry mouth and weakness. Often an adjustment to your dose will help to reduce side-effects. Always report side-effects to your doctor and pharmacist.
- Even though methadone blocks the opioid high, some people do continue to use other opioids on occasion when they start methadone treatment. Seeking out the opioid high when you're on methadone can be dangerous. Methadone is a strong opioid drug, and if you take more opioids, you might not feel high, but you'll be at risk of overdose. Talk to your doctor about using other opioids. If you feel the need to take additional opioids it may mean that your methadone dose should be adjusted.
"My advice to those who want to go on meth is think good and hard and consider other alternatives. Methadone is not a drug to get high on, and it has severe side-effects. It should not be taken lightly."
— Margaret, 41, on methadone 11 years.
"I wish I'd known when I went on meth that it would be a lifelong hell. It's a ball and chain."
— David, 36, on methadone four years.
"Methadone is not a lifelong hell! And it's not a ball and chain – unless you make it that way. If you get your shit together and it's in your fridge, you can go about your life the same as anyone else. You wake up in the morning and you take it, just like you brush your teeth and you drink your coffee."
— Richard, 45, on methadone three years.
Other treatment options
As you can see, for all its benefits, methadone does have its drawbacks. Before you decide to commit to long-term methadone treatment, consider these other treatment options.
You probably know about cold turkey, that horrible flu-like sickness that makes it so hard to kick. What you may not know is that there are ways of reducing the withdrawal symptoms, making the process easier to get through (see below). While some things can help, the most important factor in getting through withdrawal is time. Over time the sickness goes away, and the cravings come less often.
Remember that detoxification, in itself, is rarely enough to bring an end to a history of habitual drug use. When combined with a drug rehabilitation program, detoxification can be successful, especially if you are highly motivated to get off drugs.
The following options for assistance in withdrawal and detoxification can be discussed with your doctor:
- Clonidine is a prescription drug that can reduce symptoms of opioid withdrawal. It lowers your blood pressure, which can also lower your energy level, so if you take it, be prepared to rest. Ask your doctor about other non-opioid drugs (such as anti-inflammatories, antidiarrheals and antinauseants) that can help control symptoms of withdrawal.
- Methadone detox involves establishing a stable dose of methadone, and then gradually decreasing the dose until withdrawal is complete. This process may be completed within one month, or can take up to six months. Some may decide once they are on methadone that they prefer to continue with the treatment, rather than taper off.
- Acupuncture can sometimes help to relieve withdrawal symptoms, especially for those whose opioid dependence is on the milder end of the scale. The treatment involves the insertion of stainless steel disposable acupuncture needles into the ears. It is believed that the needles can stimulate the release of endorphins, chemicals in the brain that help to relieve withdrawal symptoms.
- Rapid opioid detoxification is a controversial and expensive experimental procedure that has high rates of relapse. The process involves going under general anaesthetic for five to six hours. While you are asleep, you are given a number of drugs, including naltrexone. Naltrexone is an opioid antagonist, a drug that prevents opioids from having any effect. This causes you to go into intense withdrawal. Providers of the service may claim the treatment speeds up the withdrawal process, but you can still expect to experience significant withdrawal symptoms when you wake up. The treatment includes continuing with the naltrexone. Anyone considering this treatment should question whether the risks of undergoing anaesthetic, and the cost, are justified. It is not a miracle cure.
- Following withdrawal, the drug naltrexone may be helpful in reducing the temptation to use again. Naltrexone blocks the opioid receptors in the brain, which means that even if you take opioids, you won't get high. Naltrexone is also used in the treatment of alcohol dependence. Naltrexone is available as a pill that can be taken daily. Naltrexone is non-addictive, and will not cause withdrawal when stopped.
Based on the 12-step program of Alcoholics Anonymous, Narcotics Anonymous (NA) is an association of recovering drug addicts with groups in many countries around the world.
NA members gather at informal meetings to share their personal experiences of drug addiction. The principle behind the organization is that those who have experienced drug dependence, and have found a way to deal with it, are the most qualified to offer support and advice to others who wish to do the same. The 12-step approach hinges on the belief that those who are addicted are powerless over drugs, and that through faith, reflection, reconciliation and helping others, sanity is restored.
While NA's only stated requirement of membership is "a desire to stop using drugs," they do encourage complete abstinence from all drugs, including alcohol.
Some NA groups are supportive of methadone clients and will encourage you to participate. Others may welcome you at NA meetings, but won't invite you to participate. (Some people get around this by simply not mentioning that they're on methadone.) NA members are encouraged to be drug-free, but people on methadone maintenance are committed to a long-term, drug-based treatment. Similar groups, called Methadone Anonymous, are aimed at methadone clients, and are forming in some centres. (See Chapter 6 for more information on Methadone Anonymous.)
ConnexOntario's drug and alcohol registry of treatment will provide you with a local number to call to find the NA meetings nearest to you. Call their 24-hour toll-free line at 1-800-565-8603.
Alternative addiction self-help
For those who are motivated to give up drugs, and who may not be comfortable with the 12-step approach, there are a growing number of alternative approaches to addiction recovery. Check the Web or your local library for information about approaches such as Rational Recovery and SMART (Self-Management and Recovery Training).
Day/evening and residential treatment
Day/evening or residential treatment programs for substance abuse are available across Ontario. Residential programs can be short term (less than 40 days) or long term (more than 40 days). Generally both day/evening and residential treatment are structured programs offering intensive individual and group therapy. Some long-term residential programs allow you to work or attend school while receiving treatment.
All residential treatment programs require that you be drug-free prior to admission, however more and more of them are accepting methadone clients.
To explore the options of day/evening or residential treatment, contact your local assessment and referral service (find the number by calling ConnexOntario's drug and alcohol registry of treatment at 1-800-565-8603) or talk to your doctor or counsellor.
Buprenorphine is one of the first new treatment options for opioid dependence since methadone was introduced in Canada over 40 years ago. Buprenorphine is similar to methadone in that it reduces drug cravings, blocks the effect of opioid drugs and suppresses withdrawal symptoms. Buprenorphine is regarded as an alternative to methadone and is not seen as a treatment that will replace methadone. For more information, talk to your doctor about the availability of buprenorphine (also called Suboxone) and ask if it is the right medication for you.
Weighing your options
Methadone maintenance has the best record in terms of keeping clients in treatment and off opioid drugs for the longest period of time. On the other hand, it does carry some side-effects that may be unpleasant, and it does require a long-term commitment. If you have tried one or more of the other treatment options listed, and you are still using, and you know you want to stop, methadone may be your best choice.