Edinburgh University researches followed hundreds of people living with addiction to heroin for nearly 30 years.  What did they learn?

Methadone treatment:

• reduced the frequency of drug use
• helped people lead more stable lives
• reduced the risk of death by 13% each year

Why am I not surprised?  Because I’ve seen this with my own eyes.  And these results are consistent with previous research.

Part of what interests me about this study is that researchers followed participants in the research study for decades.  That is very useful.

The study will be published in the British Medical Journal on July 17, 2010.  I will be very interested to read the details of what they found, and will likely comment further in a future post.

Relationships are never easy.  When it comes to our relationship with methadone, let’s just say it’s complicated.

Debby, the Mom at the blog How’s My Son?, recently wrote a post updating her readers on her son’s recovery from addiction to OxyContin and other opiates.  Debby is a good Mom and a good person, and I’ve been a fan of her blog for the better part of a year now.

Debby writes:

I was just saying prayers of thanks this morning for my son’s six months of sobriety.  That’s definitely debatable, because some people believe that if you are using methadone you are not sober.  As far as I am concerned, my son is not buying heroin.  He’s using methadone at a clinic that has a good reputation for dispensing this, in liquid form, and adhering to the state of California’s very strict guidelines.

The medication is working and Debby is grateful.  Yet she feels the need to qualify her description of her son as sober.  She recognizes that some people in the recovery community would not agree that her son is sober since he is taking prescribed methadone.

Methadone-assisted recovery is real recovery, but some people in the recovery community have trouble accepting that fact.  When it comes to methadone and the recovery community, the relationship is complicated.

Methadone is strictly regulated in California, which is not necessarily a bad thing –as long as the regulations are based on science and treatment effectiveness.  The problem is, some regulations are based on stigma and politics and nothing more.  In California and everywhere else, our social and political relationship with methadone is complicated.

Debby’s son’s relationship with methadone is complicated too.

He’s been sober for six months.  He was allowed to move home six weeks ago, and Debby says he’s been great.  He’s working two jobs and saving money.

Recently, Debby’s son ran out of gas and missed his appointment at the methadone clinic.  Without his methadone dose, he began to experience withdrawal sickness.  “I hate that poison that’s in his body,” Debby wrote.

Debby’s son bought some methadone from a friend.  He said he had to do it or he would be tempted to use.

Frickin’ poison.  How I pray that my son will finally be able to purge that crap out of his body.  Synthetic opiate or not, how I long for my son to be free of drugs of any kind.  I can only watch, and feel sorrow for what he’s going through.

Debby’s feelings are understandable.  But they reminded me that the complexity of our feelings about methadone is not without consequence.

Ambivalence about methadone can be a barrier to successful treatment.  Methadone treatment requires a strong commitment to recovery. Mixed feelings about methadone can make it more difficult for a methadone patient to sustain the effort it takes to be successful in treatment.

Most methadone patients do have mixed feelings about methadone treatment.  They are grateful for the often dramatic improvement methadone treatment has brought to their lives.  Yet, they wish they didn’t need it.

They wish they didn’t have to rely on a medication.  They struggle with “clinic fatigue” from having to go to the methadone clinic frequently and over extended periods of time.  Some may experience side effects from the medication.  Yet they keep at it because the treatment is working and in the end it is worth it to them.

Those who are part of a methadone patient’s circle of support often have mixed feelings about methadone too.

They are grateful for the benefits of methadone treatment.  Yet they can’t help but wish that their loved one didn’t have an addiction in the first place.

They wish other treatments would have worked.  They wish they didn’t have to worry about whether this treatment is really working or still working.  They wish that their was a cure for addiction and the whole nightmare of addiction could just be over.  They worry about their loved one taking a long term medication (even though research shows that long term methadone use is generally safe).

The problem is that mixed feelings often lead to mixed messages.  If you want someone you care about to succeed in methadone treatment, then you want to make sure that you don’t allow emotionally-driven, negative feelings about methadone treatment to turn into negative messages about methadone treatment.

You can bet that your loved one in methadone treatment is highly tuned to these messages, and they matter.

Sometimes the negative messages are subtle and inadvertent.  Other times the messages are overt and intentional.  Either way, the effect can be disastrous.

The good news is that positive messages have power too.

Messages like:

I support you in your treatment and your recovery.  I admire you for the effort you are putting into your recovery.  I understand how hard it is to do what you are doing.  I support your right to make your own treatment choices.  I support whatever path to recovery works for you.  I want you to stay in methadone treatment as long as you need to.

Methadone patients, and those who care about them should recognize that their feelings of ambivalence are normal.  But they should also monitor their feelings carefully.  Unless managed properly, these feelings can and do effect treatment outcomes.

I appreciate Debby for sharing her feelings openly on her blog.  She is a great example of a Mom who is both honestly expressing her feelings and doing a great job in supporting her son through difficult terrain.  People like Debby and her son are making heroic efforts that I think we can all admire.

Vivitrol is on the fast track for approval in the U.S. as a treatment for addiction to heroin, OxyContin and other prescription pain killers.  Here are some facts about Vivitrol:

• Vivitrol is an extended release formula of the drug naltrexone
• Vivitrol was approved for treatment of alcohol dependence in 2006
• Vivitrol was granted priority review status as a treatment for opiate dependence by the U.S. Food and Drug Administration (FDA) in May, 2010
• FDA is expected to make a decision on approval of Vivitrol as a treatment for opiate dependence in October, 2010
• Vivitrol is non-narcotic, non-addictive, and a single dose lasts one month
• Vivitrol is administered by injecting the medication into muscle

Unlike methadone or buprenorphine (brand names Suboxone and Subutex), Vivitrol is not an opiate replacement therapy.  Opiate replacement therapies treat compulsive use of fast acting opiates by prescribing therapeutic doses of longer acting, less euphoric opiates under medical supervision.

Naltrexone is not an opiate, but it has the ability to block the effects of opiates by physically occupying opiate receptor sites in the brain.

Naltrexone is already used to treat addiction to heroin or other pain killers, but usefulness of the treatment is limited by the fact that many patients simply skip doses or stop taking the medication as part of a relapse to opiate use.  A single dose of Vivitrol is active for one month limiting the temptation and opportunity to circumvent the treatment.

Methadone and Suboxone/Subutex (buprenorphine) also have medication adherence issues.  For example, many Suboxone patients in early recovery find it difficult to successfully hold their own medication and take the medication as prescribed.  Without adequate recovery supports, many patients relapse before they have a chance to establish a stable recovery.

A few concerns about Vivitrol:

• Vivitrol patients must not have used heroin, OxyContin or other prescription pain killers within 7-10 days of taking Vivitrol (this complicates the process of getting an opiate dependent person started on the medication)
• Patients who try to overcome the blockade effect of Vivitrol or who resume opiate use after discontinuing use of Vivitrol may be at increased risk for fatal drug overdose
• Vivitrol, like other formulations of naltrexone, can be toxic to the liver (this may limit usefulness for some patients with active liver disease including some patients who became infected with Hepatitis C via injection drug use)

Fifteen percent (15%) of high school freshmen in the U.S. say they have taken OxyContin, Vicodin, Adderall, Ritalin or Xanax without a doctor’s prescription.  This according to the United States Center for Disease Control (CDC) 2009 Youth Risk Behavior Survey.

By the time they are seniors, that number has grown to 26%, or more than one in four.

Note that the survey did not ask about other opiate/opioid drugs like heroin or Dilaudid, other stimulants like cocaine, or other benzodiazepines like Valium or Klonopin.  And don’t forget alcohol.

(I’m dedicating this post to Bill, the Dad at the blog Dad on Fire.  Keep up the good work Bill, and peace and safety to you and your family.)

Settlers of the American west learned that their best weapon against fire was fire itself.

Today, scientific researchers are studying the effectiveness of fighting heroin addiction by prescribing heroin.

What they are finding:

If you give medical grade heroin by prescription to people who are addicted to street heroin, they reduce or stop use of street heroin.

Um, wouldn’t it be better if they didn’t use heroin at all (you might ask)?

Of course.  But the people eligible to participate in the studies are people who have not been able to stop using heroin even with treatment.  All other treatment options have failed them, and they are looking for something that actually works.

Um, isn’t the whole point of heroin treatment to help people stop using heroin (you might ask)?

Of course not.  The point of heroin treatment is to help people stop suffering harm associated with heroin use –more specifically, use of street heroin.

Most of the harm associated with heroin use is actually only associated with heroin acquired on the black market and consumed in the context of a raging compulsive and chaotic addiction.  In comparison, much less risk of harm is associated with heroin acquired by prescription and consumed in the context of a drug treatment program under medical supervision.

It’s not demon heroin (or OxyContin or other pain killers), it’s demon addiction.

It’s hard to win the battle unless you can accurately name and recognize the enemy.

The pioneers faced their challenges head on.  It took bravery and bold thinking to fight fire with fire.  But when a prairie fire grew large and threatened to wipe out home, farm and family, that’s exactly what they did.

The settlers started their own fires.  These small, controllable fires would consume anything flammable near the homestead.  Deprived of fuel when it arrived near the homestead, the larger fire would either burn out or follow a different path away from the homestead.

I’m grateful for bold scientists, institutions, governments and people living with addiction who dare to try to fight heroin with heroin.

I’m grateful that they recognize that the ultimate goal is not to prevent drug use, but drug harm.  I’m grateful that they care more about preventing harm to people who are living with opiate dependence than they care about controlling people with opiate dependence.

And I’m grateful that they are brave enough to pursue this goal even at the risk of criticism from those with less noble motives.

The headline of this post is a mixture of fact and wishful thinking on my part.

Sure, many parents do question advice from so-called experts who tell them they should allow their daughter or son to suffer serious harm in order to allow them to hit rock bottom and stop using drugs.  But what surprises me is how many parents do not question this advice, even when it should be clear that this tactic isn’t working.

Plenty of harm is piling up, some of it irreversible, but didn’t the experts say something about all this harm leading to recovery?

I have spent quite a bit of time observing and reflecting on this phenomenon.  What could make a parent accept advice from an expert to allow their child to suffer serious harm?  What could make them persist in this course of action or inaction, even while horrible things are happening to their child right before their eyes?  What could make them persist even when it should be clear that the whole hitting bottom thing isn’t working?

Stanley Milgram might offer us a clue.  He conducted a series of now famous experiments at Yale in the 1960s.  Paid volunteers agreed to participate in a “memory experiment.”  A Yale scientist in a lab coat  told the volunteers to administer electric shocks to a study subject each time the subject gave a wrong answer.  With each wrong answer, the voltage of the shock was increased.

At 75 volts the subject grunts.  At 120 volts the subject shouts in pain.  At 150 volts the subject tries to quit.  The Yale scientist in the lab coat tells wavering volunteers to keep going, and assures one skeptical volunteer that the shocks will cause “no permanent tissue damage.”

At 200 volts the subject screams in agony, and at 300 volts stops responding to questions and mumbles something about a heart condition.  The man in the lab coat tells the volunteer to treat non-responses as incorrect answers and administer a higher level of pain.  At 450 volts, the scientist finally says the experiment is over.

The real topic of the study wasn’t memory, but response to authority.  The study subject who screamed in pain was an actor.  But the true subjects of the study, the volunteers, were average people just like you and me.

The study found that most of the volunteers would have stopped administering shocks early in the experiment.  This wasn’t easy for them.  Many showed signs of extreme stress including sweating, trembling, groaning and digging their fingernails into their flesh.  Quite a few experienced uncontrollable laughing fits, and a few actually had seizures.  But with the expert authority figure of a scientist in a lab coat encouraging them to continue, about two out of three of them administered every shock right up to the 450 volts, no matter how much the subject begged for them to stop.

This study became very famous in the field of psychology.  The findings have been confirmed and found to be true for people across gender, age, occupation and level of education.  These volunteers were not a bunch of sadists.  They were regular people like you and me.

I can’t help but wonder whether this study might shed some light on why so many parents are willing to follow bad advice and allow their addicted children to suffer serious preventable harm.  Especially when better alternatives could both prevent the harm and be more effective in helping their family member transition from active drug use to recovery.

Each of the harms is like one of those electric shocks.  And like the electric shocks, the harm tends to become more severe over time.

In trouble at school, lost a job, kicked out of the house, beat up by a dealer, arrested, incarcerated, infected with hepatitis C and HIV, traded sex for drugs or money, raped, attempted suicide, suffers a fatal drug overdose.

450 volts of electric shock would be getting off cheap.  And these aren’t strangers.  Shouldn’t we be shocked when parents intentionally stand by while preventable harm happens to their own children because they believe it when they are told that they must allow this harm to happen?

I’ve sat in groups of parents and watched them nod solemnly in assent as a so-called expert told them that they were enabling their child’s addiction if they so much as bought them a loaf of bread.

Especially in times of crisis, when we aren’t sure what to do, we look for someone who may tell us what to do.  Generally speaking, there isn’t anything wrong with consulting an expert and acting on the expert’s advice.  Our ability to follow leadership in times of crisis is a social and psychological adaptation that has served humankind well.  But we are all wise to retain our independent judgment and common sense.

Most parents are heroic in their love for their addicted children.  They deserve great respect and compassion.  Sometimes parents don’t know how to prevent harm to their children.  Sometimes parents lack the strength or capacity to continue to try to prevent harm to their children.  Some parents feel powerless to effect the outcome of their child’s addiction, and so surrender any hope that they might be able to make a difference.  Sometimes parents feel that they have to let go out of emotional self-preservation.

I support parents setting appropriate boundaries to keep themselves and other family members safe and sane.  I also support parents who want to take action to keep their child safe, and who want to take action to help them transition from active addiction to recovery.

Voices in the “tough love, anything you do to help is enabling addiction, let them hit rock bottom” crowd tend to shout the loudest.  But parents should know that the scientific research is on the side of the experts who say that early intervention is better than waiting for someone to hit bottom, and that enabling recovery requires action.

Don’t believe the scientific researchers just because they wear lab coats.  But don’t believe those in the tough love crowd who tell you that you have no choice but to stand idly by and watch the catastrophe unfold, just because they seem to speak with authority.

1.  Methadone is a medication used to treat opiate dependence

2.  Methadone prevents withdrawal, limits cravings and blocks the effects of heroin, oxycontin and other opiates

3.  Opiate dependent people who are in treatment with methadone live longer

4.  Long term treatment with methadone is better than short term treatment with methadone

5.  A low methadone dose is not necessarily the best methadone dose

6.  Methadone is the gold standard treatment for pregnant women who are opiate dependent

7.  Methadone has drug overdose risks and benefits that you should understand

8.  Methadone treatment requires a strong commitment to recovery

9.  Methadone-assisted recovery is real recovery

10. Methadone treatment is the single most effective treatment for opiate dependence

Top experts at the US Department of Health and Human Services, Center for Disease Control state that, “methadone maintenance treatment is the most effective treatment for opiate addiction.”

Find a link to the CDC Methadone Fact Sheet here:  methadone

Methadone treatment is an evidence-based treatment.  It is not based on a theory or a philosophy.  It is based on medical research.

Scientists and other experts have extensively studied methadone treatment for decades.  Methadone has a long and well documented track record of success.

Let’s consider the range of available treatments for opiate dependence, and see how methadone stacks up.

No treatment

Many people who use heroin or other opiates are able to stop using and build a stable recovery without any treatment at all.  On the other end of the spectrum, many others have tried their best dozens of times to stop using without success, even with treatment.

Most of the time, the difference isn’t about how hard they tried, how much they wanted it, or anything to do with willpower.

Instead, it’s about how long the person has used, how much they have used, whether they have a genetic predisposition for addiction, whether opiate use has changed their brain chemistry, or whether they also have mental health challenges.  It’s fair to say that those who have tried repeatedly to stop using without success have a complex addiction.

Methadone treatment is not appropriate for people who are able to stop using on their own without any treatment.  But methadone has helped many of those on the other end of the spectrum who are living with a complex addiction succeed in recovery when nothing else worked.

Self-help groups

Self-help groups, including 12-step groups like AA and NA, are a useful recovery support tool for many people.  However, self-help group participation alone is usually not enough to result in long term recovery for people with complex addiction to opiates.

Methadone treatment is not appropriate for people who are able to sustain recovery through self-help groups alone.  But methadone is appropriate for people who are not able to sustain recovery through self-help groups alone.

Methadone treatment is much more successful than self-help groups in creating the conditions for long term recovery among people with complex addiction to opiates.  Participation in a self-help group without more is unlikely to be an effective recovery plan for a person with a complex addiction to opiates.

Some people choose to use self-help groups as a recovery support while participating in methadone treatment.

Detox

Detoxification or detox is simply the process of stopping opiate use and allowing the body to readjust to functioning without taking opiates.

Detox can be done at home, through an outpatient detox program or through a residential detox program.  Detox can be done quickly by a sudden termination of opiate use, or more slowly via a gradual reduction in doses over a period of days, weeks or months.  Detox can be done “cold turkey” or with a variety of supports including use of medications like clonadine, methadone or buprenorphine.  It can even be done under anesthesia such as in so-called “rapid detox” programs (these so-called rapid detox programs are potentially fatal and are not recommended).

Detox is a necessary first step for those who are seeking recovery for those who are not participating in medication-assisted treatment with methadone or buprenorphine (Suboxone/Subutex).  But detox alone is not effective in producing a long term recovery from opiate dependence, especially among people with complex addiction.  I would compare it to one-time fasting as a way to create long term weight loss.

It’s worth noting that the need to detox is a major barrier to recovery for many people.  It’s difficult for many people to voluntarily sign up for that kind of agony –especially since many have already been through detox multiple times and already realize that detox alone has not been enough for them to achieve lasting recovery in the past.

One of the benefits of methadone treatment is that detox is not required  because methadone prevents withdrawals.  Methadone also limits the cravings that follow detoxification.  These are two of the reasons that methadone treatment program is much more likely to result in long term recovery than a detox program.

Another reason is that many people have experienced changes to their brain chemistry because of opiate use.  For these people, detox results in a brain that is deprived of what we all need to feel normal or happy.  In contrast, methadone helps the person in recovery maintain a healthy chemical balance in the brain and feel normal.

Outpatient counseling

Outpatient counseling is sufficient treatment to result in successful recovery from opiate dependence for some people.  Methadone treatment is not appropriate for people who are able to stop using with outpatient counseling alone.   But for people with a complex addiction to opiates, the combination of medication plus counseling is very powerful.  This is why most methadone maintenance programs include outpatient counseling as part of the treatment mix.

Outpatient counseling is very helpful in that it provides an opportunity for the counselor and person living with addiction to assess the addiction, address co-occurring or underlying conditions such as mental health conditions, address barriers to recovery, and create a realistic long-term recovery plan.  Outpatient counseling has the potential to be highly individualized and flexible.  And outpatient counseling can provide treatment and support over an extended period of time.

Done right, the counselor and counseling client form a therapeutic alliance that helps keep the client engaged in treatment, and helps the client build and sustain motivation for positive change.  This requires significant skill on the part of the counselor, and a good match between counselor and client.

Unfortunately, many counselors lack the skill to effectively engage clients, retain clients, build and sustain motivation, or support action toward positive change.

This is why the most common number of treatment sessions between and outpatient counselor and a person living with opiate dependence is zero (meaning the outpatient counseling program is not successful in attracting the person into treatment).  And the second most common number of treatment sessions is one (meaning the person was willing to try meeting with the counselor, but the counselor was not successful at engaging the client).  This is too bad, because these are opportunities lost.

Combining outpatient counseling with methadone maintenance significantly improves engagement, retention and treatment outcomes over counseling alone for people with complex addiction to opiates.  The addition of methadone maintenance improves the safety of the treatment both because people stay in treatment longer and because methadone limits relapse risk.  And the addition of methadone improves recovery sustainability because people tend to be more successful at achieving abstinence from harmful drugs and stay in treatment longer.

Outpatient counseling is less intrusive upon the life of a person living with opiate dependence than residential treatment.  In other words, there are fewer barriers to accessing outpatient counseling for most people than for accessing residential treatment.  For example, people can continue working and caring for their children when in outpatient counseling and this is often impossible if the person is in residential treatment.  This is an important benefit in terms of attracting and retaining clients in treatment.

Outpatient counseling is most effective in addressing complex addiction to opiates when it is combined with medication-assisted treatment with methadone.  Outpatient counseling plus medication is a realistic core treatment for a person with complex opiate addiction, and is often a solid foundation for a safe and sustainable long term recovery.

Residential Treatment

Residential treatment provides a useful interrupt for those experiencing chaotic drug use.  Residential treatment provides a safe place for a person to stay while they seek to stabilize.

Many people benefit from getting out of their usual environment for a while as they seek to initiate abstinence from harmful drugs.  Part of this is separating from harmful people and places, and the temptations they face in the community where drugs are plentiful and readily available.

Residential treatment can be a good place to detox from harmful drugs.  It can be a good place to begin taking medications that support recovery such as buprenorphine (Suboxone/Subutex) or methadone.  And it can be a time and a place for people to learn about treatment and recovery.

The combination of long term residential treatment plus methadone (or buprenorphine) is a very powerful combination that can be highly effective for people with a complex addiction to opiates –even those who have not been successful with outpatient methadone treatment or residential treatment alone.  Unfortunately, there are not many programs that combine these two elements.

Once a person leaves residential treatment, the person is at an increased risk for both relapse and fatal drug overdose.  Having a solid after care plan in place is critical because recovery success rates for people with complex addiction to opiates after short term residential treatment  alone is low.  Success after long-term residential treatment (meaning over 90 days and the longer the better) is better, but relapse is still common.

Success is improved if residential treatment was combined with medication-assisted treatment with methadone or buprenorphine.  But many residential treatment programs lack the capacity to provide medication-assisted treatment.  Many are not supportive of medication-assisted treatment on “philosophical” grounds, and therefore ignore the science of recovery to the detriment of their clients.

Many residential treatment programs have low treatment retention (lots of people leave treatment early or are discharged from treatment early).  Part of the reason is that residential treatment is very disruptive to people’s lives.  Many people are uncomfortable in the residential environment and miss the comforts of home.  Added to this is the fact that people who are newly in treatment are often detoxing, have little momentum in their recovery, and are experiencing powerful drug cravings.  Many programs lack skilled and professional staff, make no attempt to provide good customer service, and consider a confrontational approach to be somehow therapeutic.

Recovery success rates with short term residential treatment alone for people with complex opiate addiction are not good.  Short-term residential treatment is best viewed as a tool to be used for the benefits it does provide in the context of a broader recovery plan.

Success rates for long term residential treatment are better than for short term residential treatment, but not better than success rates for outpatient methadone maintenance treatment.

Sober houses/Halfway houses

Stable housing is an important part of stable recovery.  Sober houses or other halfway houses are a useful recovery support tool.  However, taking up residence in a sober house alone is usually not enough to result in long term recovery for people with complex addiction to opiates.

Success is more likely if the sober house is part of a larger plan that includes adequate treatment and other supports.

Most sober houses or halfway houses are primarily housing.  They usually offer no formal treatment.

The best include a core group of residents who are stable and have been in recovery for quite a while.

Those with a lot of turnover often are not safe places to live.  Most of the residents will be in early recovery, and some will not be in recovery at all (either they have no place else to go, or they are mandated to live in sober housing by the criminal justice system).  Some of those living in such houses are probably using or will relapse, and this can make it difficult for others to stay sober.

Many sober/halfway houses refuse to accept people in methadone treatment.  This is apparently a “philosophical” decision.  It is a counter-productive policy however, because it denies people in recovery access to housing options that may be helpful to them, and pushes away residents with a higher likelihood of stability in favor of residents with a higher likelihood of instability.

Opiate-dependent people in methadone treatment are generally more stable in their recovery than their peers who are not in medication-assisted treatment.  This is especially true for those in early recovery, and those with complex addiction.

Suboxone/Subutex (buprenorphine)

Buprenorphine (brand name Subutex, and brand name Suboxone when the formulation includes the drug nalaxone), is a medication used to treat opiate dependence.   Buprenorphine is methadone’s strongest competition in the contest for the title, “Single Most Effective Treatment for Opiate Dependence.”

Buprenorphine treatment shares many of the characteristics of methadone as a medication-assisted treatment for opiate dependence.  Their are two reasons that buprenorphine can’t quite take the Most Effective title away from methadone.

First, buprenorphine has a “ceiling effect.”  This means that at some point, taking a higher dose of buprenorphine will have little or no additional effect.  For some people, there is no effective dose of buprenorphine.  For these people, methadone offers a broader range of effective dosing options.  In this sense, methadone is a “stronger” medication.  Methadone is able to provide a therapeutic dose to a broader range of people with opiate dependence.

Second, buprenorphine is commonly prescribed by private doctors in office-based settings.  This means that the medication usually comes with little monitoring and few supports.  For an opiate-dependent person in early recovery, this can be challenging.  It takes a certain level of recovery stability for a buprenorphine patient to hold their own medication.  This is because buprenorphine has a street value, and can be sold for cash or traded for other drugs.

In contrast, methadone treatment for opiate dependence must be provided in a clinic-based setting.  And under federal law, the clinic must hold the medication for the patient and provide the medication at the clinic in daily doses.  It takes months for patients to earn the right to have limited take home doses under federal regulations.  This can create barriers to treatment and recovery.  But it also supports people in early recovery stabilize in recovery.

In combination, these two differences make methadone a more effective treatment for many people with complex addiction to opiates.

Conclusion

Much maligned and often misunderstood, methadone remains a wonderful gift.  A gift that has saved thousands of lives, held together families, and brought hope and success to many who felt hopeless and defeated by their addiction.

Methadone is not a magic bullet, and it is not an appropriate treatment for everyone.  But if you care about people with opiate dependence, I urge you to speak up and help others understand the value of this important path to recovery.

Celebrity rehab doctor Drew Pinsky recently suggested that actress Lindsay Lohan’s father plant drugs in her car and call the police as a way to get his daughter arrested and into drug treatment.

After he was widely criticized, he wrote a letter published on the Huffington Post seeking to clarify his position –without really changing his position, or apologizing for suggesting that the father of an adult woman should commit a felony so that his daughter will be falsely arrested and imprisoned.  He repeated that if he were Lindsay’s father he would “go to any lengths to get her to and retain her in treatment.”

See the MSNBC News article or the Huffington Post letter for more details.

It’s too bad that Pinsky is so quick to violate his oath as a doctor to “first do no harm.”

It’s too bad that he is so cavalier about putting a young woman at serious risk through arrest and incarceration.  He is also remarkably naive to think that he can rely on an “enlightened judge” to provide any particular sentence.  Many people have learned the hard way that once a loved one is in the jaws of the criminal justice system, things get unpredictable, and collateral damage and unintended consequences can be severe.

And it’s too bad that Pinsky does not have the knowledge and skills necessary to engage and retain his patients in voluntary treatment, and instead must resort to crime and coercion.

Pinsky creates drama to justify his extreme views.  But the reality is that “tough love” treatment providers like Pinsky (even those who aren’t trying to be famous) talk big but rarely actually “go to to any length” to engage and retain patients in treatment.  More often they make people jump through hoops to get treatment, treat patients in a way that is unlikely to retain them in treatment, and then kick them out of treatment for minor rule violations.

Opiate dependent young people ages 15-21 did better with 12 weeks of treatment with Suboxone as opposed to a 2 weeks of treatment with Suboxone.  This according to new research funded by NIDA (US National Institute on Drug Abuse).

The findings held true even for teens and young adults with shorter durations of addiction.

Better outcomes included better treatment retention, less opiate use, less marijuana use, less cocaine use and less injecting even a year after the treatment.

“The results of our study suggest that there is no hurry to stop providing buprenorphine-naloxone, an effective medication, regardless of a patient’s short duration of opioid abuse,” said study author Dr. George Woody.  “In my experience as a clinician, most opioid abusers –adolescent or adult –prefer to get off medication eventually.  When to stop medication is an individual decision that depends on a patient’s response to treatment, his or her commitment to achieving full remission without medication, and whether he or she has attained a sustained period of abstinence and stable overall living situation.”

The report noted that further studies are needed to find out whether even longer treatment with Suboxone would be even more effective.

Based on my experience working with many opiate dependent people, I anticipate that further research will document that lengthening the period of treatment with Suboxone even further will result in even better treatment outcomes in this age group.

Read the full article in NIDA Notes here and the full study report here.

1.  Methadone is a medication used to treat opiate dependence

2.  Methadone prevents withdrawal, limits cravings and blocks the effects of heroin, oxycontin and other opiates

3.  Opiate dependent people who are in treatment with methadone live longer

4.  Long term treatment with methadone is better than short term treatment with methadone

5.  A low methadone dose is not necessarily the best methadone dose

6.  Methadone is the gold standard treatment for pregnant women who are opiate dependent

7.  Methadone has drug overdose risks and benefits that you should understand

8.  Methadone treatment requires a strong commitment to recovery

9.  Methadone-assisted recovery is real recovery

10.  Methadone is the single most effective treatment for opiate dependence

People in the recovery community often have strong feelings about methadone.

I guess everyone is entitled to their own opinion.  But people are are not entitled to their own facts –especially when their misrepresentation of the facts harms other people.

People in methadone treatment often face discrimination, even within the recovery community.  Some are told they are not allowed to speak in 12-step meetings.

Many “sober houses” do not accept people in methadone treatment.  There is sad irony in this given the fact that most sober half-way houses experience high turnover due to relapse, and methadone treatment limits relapse.

Uninformed talk suggesting that people in methadone treatment are not “really sober,” or are not in “real recovery” results in serious harm to already vulnerable people.  That kind of talk discourages people from participating in a proven treatment that often literally saves lives.  This is serious stuff.

Let me state clearly that methadone-assisted recovery is real recovery.  Very real.  And yes, that is a fact.

Let me walk you through this:

Opiate dependence is diagnosed and defined under the DSM-IV TR (Diagnostic and Statistical Manual of Mental Disorders) by the existence of a “maladaptive pattern” of opiate use leading to “clinically significant impairment or distress.”

The diagnostic term “opiate dependence” is a term of art that is really about more than just physical dependence on the drug.

Opiate dependent people use opiates in an unhealthy way, and they persist in this unhealthy pattern of use in spite of negative consequences.

Most of us call this “addiction.”

This is why the person recovering from surgery who is physically dependent on opiates (they would go into physical withdrawal if they abruptly stopped taking opiates) would not be diagnosed as “opiate dependent” under the DSM-IV TR.  The surgery patient is taking the opiates in a healthy way that results in positive consequences –not in a maladaptive way that results in negative consequences.

Negative consequences linked to opiate dependence include financial hardship, loss of employment, loss of child custody, incarceration, homelessness, overdose, and health problems including abscesses, HIV and hepatitis C.  These consequences also often include estrangement from significant others, family and friends.

Substances in the opiate family generally do not cause, in and of themselves, serious damage to the body (unless the person overdoses).  This is true even for long term opiate use.

This isn’t to say that a maladaptive pattern of opiate use does not result in harm.  It’s just that the harm associated with opiates is really less about harm to the body caused by the substance itself, and more about how maladaptive use interferes with social functioning, or how use results in injection-related harm.

Methadone is a medication that supports opiate dependent people in ending the unhealthy pattern of opiate use. Just as importantly, methadone helps opiate dependent people recover from the harm they have already suffered because of their unhealthy pattern of opiate use.  And it helps them avoid suffering new harm.

For example, the heroin addict loses her job, and the methadone patient finds she is able to hold a job again.

The opiate dependent person shares syringes and becomes infected with hepatitis C; while the methadone patient stops injecting, and finds his life is stable enough to participate in medical treatment for hepatitis C.

Oxycontin misuse lands the opiate dependent person in jail; while the methadone patient finds that she no longer is driven to crime, and is able to successfully complete probation.

This is called recovery.  And it is real.

Let’s take a closer look.

I like to say that “real recovery” is safe and sustainable.  How does methadone-assisted recovery stack up?

Methadone-assisted recovery reduces risk and enhances safety.

Statistics show that opiate-dependent people in methadone treatment are less likely to overdose, and are less likely to become infected with HIV or hepatitis C.  They are also less likely to experience homelessness, joblessness, violence, incarceration or loss of child custody.  They live longer.

Methadone improves treatment retention, limits relapse, and enhances stability in recovery.

Involuntary discharge and drop-out rates are high for most other forms of treatment for opiate dependence.  This results in unstable recovery.

This is true of detox programs, outpatient counseling programs, 12-step programs, short term residential treatment programs and long term residential treatment programs.

This isn’t  to say that these other forms of treatment don’t have value.  Each works for some people some of the time, and each is a recovery tool that has value when used properly as part of a comprehensive recovery plan.

The important point to notice is that people in methadone treatment often stay in treatment for years or decades –all the while enjoying the health benefits of recovery, and all the while avoiding the relapses and destructive cycles that are so common in other forms of treatment.

The healing that flows from recovery can only happen if the treatment results in long term stabilization.

Relapse places people at serious risk.  Constant cycling between chaotic use, incarceration, detox, and residential treatment contributes to instability in recovery, and exacerbates many of the harms associated with opiate dependence.

Methadone helps create the conditions necessary to build a safe and sustainable recovery.

Methadone promotes REAL RECOVERY!