Methadone maintenance

Introduced as an analgesic in the US in 1947, methadone has been used in maintenance treatment—also known as substitution treatment, or drug replacement therapy—since 1964.[5] Therapeutic dosing is contingent upon individual patient needs, with a dosage range generally between 20 and 200mg. Doses are unsafe for opioid-naive individuals, and administration of methadone is gradually increased to reach a therapeutic dose under medical supervision to reduce the risk of overdose.[6][7] The amount of oral methadone a patient will require is dependent on the amount and power of opioids they consumed prior to initiating treatment, with an assessment in the mid-2000s (prior to the widespread introduction of fentanyl into street heroin supplies in the US) finding that 1 gram of street heroin is roughly equivalent to 50 to 80mg of methadone.[8] Methadone is taken either orally as a mixture of 1mg/1ml supplied as a red or clear liquid, or as a mixture containing 10mg of methadone in 1ml of liquid (green color) or 20mg in 1ml of liquid (brown color). The latter is often used when a person is on a large amount of methadone, and is rarely permitted for unsupervised consumption. Since the formulations are not as viscous as the 1mg/1ml mixture, they are more prone to misuse since they are easier to inject, and due to the high risk of overdose if diverted to an individual not accustomed to such a large dose. Methadone also comes in 40mg dispersible tablets called "diskettes", as well as 5 and 10mg pills that are round or "coffin" shaped. These pills are only given in hospital settings. Methadone can also be delivered by either IV or IM injection, as well as ampoules which come in various strengths ranging from 10mg up to 50mg. This method is often used for individuals who have a "needle fixation" and who would otherwise revert to using IV heroin.[8]

With the emergence of other medications for the treatment of opioid addiction such as buprenorphine and long-acting naltrexone, MMT is no longer the dominant medically assisted addiction treatment.[9] The manufacturers of naltrexone have marketed it as superior because it is not an opioid. This argument has moved criminal justice officials to prefer the medicine, and has triggered a Congressional investigation about mismarketing.[10] No study has found naltrexone to be superior to methadone or buprenorphine, and a real-world review of patient records suggests that methadone and buprenorphine are superior at reducing overdose risk or the need for acute drug dependence treatment.[11]

Methadone maintenance generally requires patients to visit the dispensing or dosing clinic daily, in accordance with state-controlled substance laws. Methadone, when administered at constant daily milligram doses, will stabilize patients so they feel a "high" from it and will not require additional street opioids. Most clinics will work with patients to get to a dosing level that will take away all cravings for other opiates without feeling too much of a "high" so they can function correctly throughout their day.[5]

In the U.S., patients that attend methadone clinics regularly and abstain from the use of street opioids or other controlled substances can be permitted to take home doses known as privileges, though this is at the discretion of the clinic's medical staff. Depending on the state's law, some clinics will allow the use of drugs like cannabis and still permit take home doses.[8] Some states allow methadone clinics to close on Sundays and provide take-home medication the day before. Clinics that offer take-home privileges will usually do so by slowly offering more take-home days over a period of time, as long as their standards of clean drug tests are met. In some states, these take-home privileges can work their way to people getting take-home doses that would last them 2–4 weeks maximum. Another way take-homes are permitted is if the clinic puts the patient on a split dose schedule where they take part of their dose in the morning and take home a dose to take later in the day. This is usually given out to people on higher doses, or to help lengthen effectiveness throughout the day. States may mandate drug testing in clinic drug abuse groups and/or outside Narcotics Anonymous meetings. In other countries, dispensing of methadone maintenance by pharmacies, or via prescription from general practitioners rather than specialized clinics, is permitted.[12]

In the UK, patients on methadone maintenance who wish to travel overseas are subject to certain legal requirements surrounding the exportation and importation of methadone. The prescriber must be provided with details of travel, after which the they will arrange for a Home Office Export License to be provided. This license is only required if the total amount being exported exceeds 500mg. Granting of the license does not allow for the importation of methadone into any overseas jurisdiction. For importation, the patient should contact the embassy of their destination country and request permission to import methadone onto their shores, although not all countries allow the importation of controlled drugs. The license also allows for the re-importation of any remaining methadone back into the UK. It is normal for patients traveling overseas to be prescribed methadone in a tablet form, as tablets are easier to transport. For patients who expect to be overseas for a prolonged period of time, "courtesy" arrangements can be made at a local clinic which arrange for the prescription of the necessary medication.[8] If traveling throughout the United States, state or city clinics may offer "take home" doses for the period of time patients will be gone. Depending on length of travel or clinic rules, they may opt to have your "courtesy" dose at another clinic that is closer to where they are travelling.

Methadone maintenance is also known as drug replacement therapy or opiate replacement therapy (ORT), and has been the subject of much controversy since its inception.[13][9] Opponents note that methadone prescription replaces dependence on one opioid with another, that methadone maintenance does not prevent additional use of heroin or other opioids in addition to methadone, and that the stabilization or "blocking" effect on euphoria can be overridden with the use of other opioids or with benzodiazepines.[14]

In England and Wales, criminal justice drugs workers employed by the 'Drug Interventions Programme' are based in most arrest suites nationwide. Heroin and crack cocaine users are identified either by mandatory urine tests, or by cell sweeps and face-to-face discussions with arrestees. Identified drug use will often trigger a referral to local drug services, whose first-line response to heroin dependence is likely to involve substitute (buprenorphine or methadone) prescribing.

This line of work originated in the mid to late 1990s, as large-scale studies identified significant levels of heroin and crack cocaine use in populations of arrestees. In a large-scale study of drug misuse in arrested populations, 466 'drug misusing repeat offenders' were identified. Of these, 80% declared an 'unmet need for treatment'.[15]

Contemporaneously, the National Treatment Outcomes Research Study (NTORS) found high levels of money-related offenses in populations of people seeking community treatment for drug problems. In a NTORS report, researches found that every £1 spent on drug treatment could yield between £9.50 and £18 of savings in social costs, mostly attributable to reductions in treatment seekers' levels of offenses.[16]

These studies, along with others,[17][18][19] were taken on by Tony Blair whilst still Shadow Home Secretary, as Conservative policy regarding drug misuse was relatively undeveloped. Blair disseminated a press release in 1994 entitled 'Drugs: the Need for Action', claiming that drug misuse caused £20bn of money-related crimes each year. This report was dismissed by the Conservative Secretary of State for the Home Department as 'four pages of hot waffle against the Government, with three miserable paragraphs at the end'.

After winning the UK general election of 1997, Blair's first cross-governmental drug strategy established the nationwide development of an integrated drugs and crime strategy as a priority. Drugs workers were in police custody suites nationwide, and saw 50,000 people in 2001.[20] The work of these teams was then formalised in 2003, given an expanded remit (working with prisoners following release, for example), and rebadged the Drug Interventions Programme (DIP).

The founding strapline for DIP was 'out of crime, into treatment', reflecting the crime-reduction philosophy behind criminal justice drug treatment and ongoing methadone (or buprenorphine) maintenance at that time. In their 2010 Drug Strategy, the Conservative/Liberal Democrat coalition stated their continued intention to support DIP.

• Opioid use disorder
• Stimulant maintenance

• U.S. National Library of Medicine - Methadone Definition
• Directory of U.S. Methadone Maintenance Facilities