Overview of methadone maintenance treatment
What is methadone maintenance treatment?
Methadone maintenance treatment (MMT) is a comprehensive treatment program that involves the long-term prescribing of methadone as an alternative to the opioid on which the client was dependent. Central to MMT is the provision of counselling, case management and other medical and psychosocial services.
Methadone is a long-acting opioid agonist that is prescribed as a treatment for opioid dependence and the management of chronic pain. MMT addresses only the treatment of opioid dependence.
Methadone may be substituted for other opioids because tolerance to one opioid, such as methadone, also blocks the effects of other opioids. This phenomenon is known as cross-tolerance. Cross-tolerance develops between substances that act on the same types of receptors in the brain. For example, people who have built up tolerance to morphine are also tolerant to other opioid agonist drugs.
Methadone is taken orally and dispensed in about 100 millilitres of liquid that does not lend itself to injection (usually an orange drink, such as Tang). Once the client is stabilized at the right dose, methadone will:
- suppress opioid withdrawal symptoms
- reduce cravings for opioids
- not induce intoxication (e.g., sedation or euphoria)
- reduce the euphoric effects of other opioids, such as heroin.
Benefits of MMT
Methadone alleviates the symptoms of opioid withdrawal. Once methadone reaches a sufficient level in a client's blood, his or her cravings are reduced. Methadone is longer acting (24 to 36 hours) than most other opioids. For example, heroin, which is short acting (three to six hours), is often injected several times a day while, in MMT, methadone is administered only once a day.
Tolerance to methadone develops slowly, so clients can be maintained in MMT indefinitely. If it is prescribed properly, methadone is considered medically safe as a treatment for opioid dependence.
Research shows that methadone is a cost-effective treatment for opioid dependence (Ward & Sutton, 1998; Rufener et al., 1977). A variety of studies have found that MMT is associated with a reduction in:
- the use of other opioids
- injection drug-related risk behaviours
- high-risk behaviour associated with the transmission of HIV and other sexually
- transmitted diseases
- criminal activity.
In addition, MMT improves:
- physical and mental health
- social functioning
- quality of life
- retention in treatment programs.
For all of these reasons, increasing access to methadone maintenance treatment is a priority. Efforts to overcome barriers to access have included increasing awareness among health professionals of the benefits of MMT and increasing recognition of the need for services that are flexible and focus on the client's needs.
For a more in-depth discussion of methadone in the context of MMT, see Chapter 3 of Methadone Maintenance: A Counsellor's Guide to Treatment.
The pharmacokinetic properties of methadone are also discussed as part of the CAMH online course on opioid dependence.
The treatment team
In specialized MMT programs, physicians commonly work closely with on-site counsellors. A cohesive treatment team, which may include an on-site pharmacist and/or a nurse, makes therapeutic decisions. In other situations, MMT involves pharmacists and counsellors working in the community. In all these situations, good communication among all those involved is essential to providing safe and effective MMT.
Regulation of MMT
The provision of methadone is highly regulated both under Canadian law and in Ontario by the College of Physicians and Surgeons of Ontario (CPSO). Methadone is defined as a Schedule 1 drug under the Controlled Drugs and Substances Act. As a result, a physician is required to follow the CPSO's process for obtaining a legal exemption before prescribing the drug, either for pain management or as a treatment for opioid dependence (see section 56, Controlled Drugs and Substances Act).
While pharmacists are currently not required to seek special permission to dispense methadone, the Ontario College of Pharmacists has established a set of policy guidelines (including completing CAMH's online course on opioid dependence) that pharmacists are expected to adhere to. CAMH has also produced Methadone Maintenance: A Pharmacist's Guide to Treatment, which is intended to support pharmacists working in this challenging area.
In overview of methadone maintenance treatment
- What is methadone maintenance treatment?
- Screening and assessment in MMT
- Assessment: Physician
- Assessment and treatment planning: Counsellor
- Initial challenges for clients and counsellors
- Assessment process
- Phases of treatment
- Stabilization phase
- Action and maintenance phase
- Tapering phase
- MMT for clients with infectious diseases
- MMT for clients with concurrent mental health problems
- MMT for clients who are pregnant
- MMT for clients who are homeless
- MMT for clients in rural or remote settings
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