Consider methadone treatment’s successes

In recent years, our communities have debated how best to manage Maine’s raging epidemic of opioid addiction. The question invariably arises whether providers and consumers of methadone maintenance are part of the solution or part of the problem. Recently, some municipal leaders and social services providers have voiced their opposition to methadone maintenance therapy. They have echoed common beliefs: methadone maintenance treatment substitutes one addictive drug for another; it offers a legal way for people to get high; recovery from addictive disease comes from one’s internal change, not from taking a pill.

Unfortunately, these misconceptions further stigmatize an already stereotyped and disenfranchised group of people who suffer from addiction. This slows Maine’s ability to address its opioid addiction problem. It directs our focus away from the goal of developing a range of treatments to a debate about which treatments are better or worse, based on opinion rather than on science.

Methadone maintenance therapy is not new. It has been utilized worldwide since the 1960s and studied more than any other addiction treatment. It consistently has been shown to reduce criminal activity and improve health, employability, and other lifestyle factors among the opioid-addicted population. As researchers have continued to study how the brain works, our medical understanding of the mechanisms that are affected by illicit opioid use has increased, leading to a better understanding of how and why methadone maintenance works so effectively.

We know the human brain contains many opioid receptors – specially configured proteins located on the surface of the brain. These receptors produce physiologic effects when activated by natural opioids such as the endorphins our bodies produce. More specifically, scientists understand that one set of these receptors, the “mu” opiate receptors, are internally calibrated to record and manage the experiences of pain, joy, motivation and mood. They even help regulate sleep and appetite.

Unfortunately, man-made opioids, including legally manufactured pain medications and illegal substances such as heroin, also attach to these mu opiate receptors, triggering pleasure messages to the brain, resulting in an instantaneous surge of pain relief and euphoria. Unable to recognize the difference between the externally consumed opioid and its own natural endorphin, the mu opiate receptor’s calibration is quickly deranged. This derangement can be chronic, lifelong, forever.

Individuals’ experience of this is acute and debilitating. Even after they stop taking opioids, they experience a protracted state of withdrawal, of not feeling “normal,” that can last six months or longer. They cannot sleep, their appetite is minimal and they experience profound anxiety, depression and irritability. They feel an intense craving for opioids, and they very frequently relapse and resume using them.

While personal counseling and behavioral therapies are important to use in conjunction with drug replacement treatment, they alone do not reduce the relapse risk for severely opioid-addicted people. Just as individuals with Type 2 diabetes often require insulin to regulate their blood sugar, opioid-dependent people often require replacement therapy to re-regulate their endorphin system, or their disease remains unmanageable.

This is where methadone fits into the equation. Not all opioids are the same. They differ in their potency, their attraction to the mu opiate receptor, and their half-life, or the amount of time it takes for them to break down in the body by 50 percent. The shorter the half-life, the higher the addictive potential. Unlike the opioids typically abused on the street, which have half-lives of four to six hours, methadone has a half-life of between 24 and 36 hours. This allows the patient to take a dose of methadone and then function in a stable manner without the four-hour cycles of euphoria and withdrawal characteristic of short-acting opioid abuse.

Buprenorphine, another therapeutic drug used in medication-assisted treatment, has a relatively short half-life, but its affinity for the mu receptor is so intense that it can take up to several days to dissociate from it. Sold as Suboxone or Subutex, buprenorphine works very well for some people. But because it is chemically less potent than methadone, it is often not effective for people with deeply entrenched addictions.

Buprenorphine offers an excellent additional tool for medical providers to use in treating opioid addiction, but it is not a replacement for methadone maintenance. Both medications represent important treatment options, with distinct advantages and disadvantages.

The reality is that for every patient who experiences negative side effects from methadone maintenance treatment or continues to struggle with opioid or other addictions, there are more than 10 patients who stabilize on the therapy. Unless you work within a methadone treatment program, you would not know this. These people are invisible. They look like you and me. They work, they drive, they make safe decisions, they go to doctor’s appointments and arrive on time, they shop at the malls and go to the beaches in the summer. They play with their children. Their health is often much improved and their participation in criminal activity drops significantly after treatment. A vast majority of methadone-maintained patients remain in treatment for years because they know it works for them. These people remember the violent, dangerous, chaotic and unhealthy worlds they came from when they were in the throes of addiction, and they do not want to return.

As the people of Maine continue their passionate debate for and against medication-assisted treatments for opioid addiction, they would be well served to consult the science and the data behind all the approaches. And as we continue to coordinate responses to this devastating problem through coalitions involving law enforcement, schools, health care providers and other community groups, our focus should be on extending the availability of both methadone and buprenorphine treatment, not restricting one or the other.

Brent Scobie is the director of substance abuse services at The Acadia Hospital in Bangor.

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