Chapter 2 - Learning about methadone​

From: Methadone Maintenance Treatment: Client Handbook

In this chapter:

• What's an opiate, what's an opioid?
• How do opioid drugs work?
  • Endorphins 
  • Opioids
• Opioid dependence
• How MMT works
• The history of methadone and methadone maintenance
• MMT in Ontario

What's an opiate, what's an opioid?

The term "opiate" refers to drugs derived from the opium poppy, such as opium, morphine and codeine, and to drugs that are derived from the opium poppy and then chemically altered, such as heroin. The term "opioid" is like a family name that includes opiates, and also other drugs that have morphine-like effects, but are not made from the opium poppy. These drugs are made by chemists in labs, and include methadone, Demerol, OxyContin, Percocet, Dilaudid and others.

How do opioid drugs work?

Endorphins

Your body produces its own opioid drugs, called endorphins. Endorphins are your body's natural painkillers.

Inside your brain is a number of what are called "pain receptors." Their job is to tell you when pain is happening in your body. For example, if someone steps on your toe, your pain receptors light up and you cry "Ow."

At first the pain is quite intense, but by the time the toe stepper is telling you how sorry he or she is, it doesn't hurt quite so much. While your pain receptors have told you to feel pain, they are also signalling to your endorphins to come and relieve the pain. The endorphins "fill up" your pain receptors, so in a few minutes the pain in your toe seems trivial.

Endorphins can boost your mood too, and affect how you respond to situations of stress. Exercise is a great way to release endorphins. Take a closer look at those all-weather joggers you see running around the park every day. See the sweat pouring off them, see the glow in their faces. They're hooked on "runner's high."

Opioids

What happens if you fall and break your arm? Your body won't produce enough endorphins to knock out that much pain. Inside your brain many of your pain receptors are still empty, and they're screaming out to be filled with something to take away the pain.

In situations like this, it's fortunate that opioid drugs can fill up the pain receptors in the same way as endorphins. What's more, the strength of the opioid drug and the dose can be adjusted to address the intensity of pain, as needed. You might be moaning and groaning when you get to the hospital, but once your doctor gives you a shot of morphine, you can sit there and be reasonably comfortable while he or she sets your broken arm and puts it in a cast. Before you go home, he or she gives you a prescription for codeine pills, so you won't have to suffer while the arm gets better.

For most people, a situation like this would be the only time they take opioid drugs. Once the arm begins to heal and the pain becomes tolerable, they stop taking the codeine, and don't give it a second thought.

Opioid dependence

But what if the pain doesn't go away? What if the only thing that can bring relief is opioid drugs? You might continue to take them, and since you like the way they make you feel, you get some more. After a while, if they're not working as well as they used to, you take more at a time, or you try a stronger opioid. You think you can stop when you want to, but when you do try to stop, you get sick, and can't stop thinking about starting up again. Eventually much of your time, energy and interest may be absorbed in getting and taking drugs. Your body has adapted to having the drugs, and now you feel like you have to have them.

This is, of course, only one way that opioid dependence can begin. Some get into it for kicks, seeking out new experience and finding one that is pleasurable and predictable, for a while. Some are seeking relief from the daily grind of poverty, from emotional hardship or from depression. Some may be drawn to the reckless image of the drugs, wanting to see themselves as "cool" or "hip."

Once you get into it, you may go on using for a long time, knowing that it's dangerous, knowing that the pleasures are short-lived and superficial. You know the drugs keep you away from people and things that matter to you. Perhaps you will be able to stop using on your own and "grow out" of your dependence. Perhaps you'll find that the support of counselling and group therapy gives you the strength to stop. Perhaps you'll try to stop again and again and keep on going back. Your health, your home, your finances and your relationships may slip into a state of chaos. You need a chance to put your struggle with the drugs aside, and take the time and the thought to sort out the rest of your life.

Here's where methadone maintenance treatment can help.

"It takes some time to get a steady dose, to start working with your body, and then you'll be okay. You have to be motivated, you cannot just expect to do nothing, sit down and wait while methadone does the job for you. If you are serious about it, yes, this is the kind of break you need."

— Amir, 35, on methadone one year

How MMT works

Methadone is a long-acting opioid drug. It fills up the same receptors in your brain as other opioid drugs and your own endorphins. While methadone can be used to relieve pain, it is most noted for its role in stabilizing the lives of people who use opioid drugs.

Methadone, through MMT, replaces the opioid drug you've been using. When methadone is taken orally, it does not produce a high, it controls your craving for opioid drugs, and it can prevent the onset of withdrawal for 24 to 36 hours. Once you're on a stable dose of methadone, you should feel "normal," and be able to focus your life on things other than drugs.

Taking other drugs while on methadone can be both fruitless and dangerous. Because methadone is an opioid, it blocks out the effects of other opioids, preventing you from getting high. The danger here is that if you take a hit and you don't feel it, you may take more and increase the risk of overdose. (For more information on methadone and other drugs, see Chapter 5.)

"Once I went on methadone I stopped getting the cravings, whereas when I was trying to stay abstinent, I just couldn't... Since I've been on the program, I can count on my fingers how many times I've used, and that was mostly at the beginning, during the first six months, that was a real shaky time for me. And besides that, I've been slowly getting my life together. It hasn't been fast, but things are coming together."

— Marco, on methadone 15 months

The history of methadone and methadone maintenance

Methadone was first discovered in Germany before the Second World War. When the supply of morphine to Germany was cut off by the Allied forces, methadone was manufactured as a painkiller. After the war, the Americans seized the formula, and methadone was produced by drug companies.

Methadone's first role as a treatment for opioid dependence was to ease the process of withdrawal. It is still used for this today.

The potential of methadone as a maintenance treatment for opioid users was discovered during a study conducted by Drs. Marie Nyswander and Vincent P. Dole in New York in the 1960s. The study involved two people who had a chronic opioid addiction with long criminal records related to their addiction. The doctors hoped to show that when the subjects of the study were given enough drugs to satisfy their craving and keep them free of withdrawal, they would no longer commit crimes, and they'd become interested in other things.

The subjects of the study were given frequent doses of morphine to keep them comfortable. Sure enough, the subjects showed no interest in crime or other drugs. However, other than watching a bit of TV, they showed little interest in anything. All they did all day was relax on the couch, either nodding off, or asking for their next shot.

Nyswander and Dole were ready to declare their experiment a failure. To prepare their subjects for withdrawal, they put them on methadone, intending to gradually taper down the dose. To everyone's surprise, once on methadone, the subjects perked up, showed little desire for drugs, and began to talk of other interests. One asked if he might be given some paints so that he could renew his love of painting. The other asked if he might go back to school. The doctors had found what they were looking for! With an adequate dose of methadone, their subjects were comfortable, clear-headed and able to renew their lives.

"...you can't ask most drug addicts to stop and consider what vocation they want to go into, or to evaluate anything, so long as their primary preoccupation is to get drugs. When an addict no longer has to worry compulsively about his source of supply, then he can concentrate on other things. At that point, rehabilitation can become a meaningful word."

— Dr. Marie Nyswander*, co-founder of methadone maintenance treatment

*Quoted in A Doctor Among the Addicts by Nat Hentoff, Rand McNally, 1968

MMT in Ontario

In 1996, there were 650 clients receiving methadone maintenance treatment in Ontario; 11 years later  there were more than 17,000. This huge leap has less to do with an increase in opioid drug use in Ontario, and more to do with a current trend in public health policy. This trend aims to reduce the damage of drug use. An early sign of this trend, known as "harm reduction," was the sprouting up of neighbourhood needle exchanges aimed at controlling the spread of HIV and other infections.

Although MMT has been available in Ontario for many years, there were few doctors authorized to prescribe it, and few specialized clinics to dispense it. Even if you were an ideal candidate for methadone treatment, and you were eager to get started, it might take years before you could begin. Unable to get quick access to effective treatment, people were contracting life-threatening diseases from sharing needles, and dying from overdose at an alarming rate.

In response, changes were made to make it easier for doctors to qualify to prescribe methadone. New guidelines for the treatment of opioid-dependant patients with methadone were made available to doctors and pharmacists. More clients might now receive their treatment from their family doctor, and pick up their dose at the local pharmacy.

This increased access to methadone maintenance treatment has meant that more and more Ontario drug users have been able to leave opioid drugs like heroin and OxyContin behind, and get on with their lives.

"Since I started on methadone, I've become a caring and involved husband, father and taxpayer. I've found my life's work, and I'm free of the crushing physical and mental burden of having to use illegal opiates. The nine months I had to wait to get on meth were torture, just torture. I was using, but I was not enjoying it. I had a real desire to change."
— Jeff, 42, on methadone six years