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IDU

HIV FEBRUARY 2002

PREVENTION

METHADONE MAINTENANCE
TREATMENT
Methadone maintenance treatment (MMT) can help injection drug users (IDUs) reduce or stop injecting
and return to productive lives. However, its use is still sometimes publicly controversial and many factors
limit the effectiveness of MMT services. New federal regulations, which have overhauled the MMT system,
promise a more flexible approach and improved delivery of these needed, life-saving services.

Opiate Addiction Is a Major Individual tor sites affected by heroin and other such as HIV, hepatitis B or C,
and Public Health Problem opiates. Methadone: bacterial infections, endocarditis, soft
• blocks the euphoric and sedating tissue infections, thrombophlebitis,
It is estimated that at least 980,000 tuberculosis, and STDs;
effects of opiates;
people in the United States are currently
addicted to heroin and other opiates • relieves the craving for opiates that is • reduced mortality – the median death
(such as oxycontin, dilaudid, and a major factor in relapse; rate of opiate-dependent individuals in
hydrocone). They risk premature death MMT is 30 percent of the rate of
• relieves symptoms associated with with­ those not in MMT;
and often suffer from HIV, hepatitis
drawal from opiates;
B or C, sexually transmitted disease • possible reduction in sexual risk
(STDs), liver disease from alcohol • does not cause euphoria or intoxication behaviors, although evidence on this
abuse, and other physical and mental itself (with stable dosing), thus allow­ point is conflicting;
health problems. It is estimated that ing a person to work and participate
5,000-10,000 IDUs die of drug over- normally in society; • reduced criminal activity;
doses every year. Many are involved • improved family stability and
• is excreted slowly so it can be taken
with the criminal justice system. employment potential; and
only once a day.
A 1997 National Institutes of Health • improved pregnancy outcomes.
(NIH) report estimated the financial costs Methadone maintenance treatment, a
of untreated opiate addiction at $20 program in which addicted individuals Using commonly accepted criteria for
billion per year. These costs, combined receive daily doses of methadone, was medical interventions, several studies
with the social costs of destroyed fami­ initially developed during the 1960s as have also shown that MMT is extremely
lies, destabilized communities, increased part of a broad, multicomponent treat­ cost-effective.
crime, increased disease transmission, and ment program that also emphasized
increased health care costs, mean that resocialization and vocational training. Key Issues in Effective Methadone
opiate addiction is a major problem for Maintenance Treatment
Methadone maintenance treatment has important
affected individuals and society. benefits for addicted individuals and for society. Dose
Methadone Maintenance These benefits include: Most patients require a dose of 60-120
Treatment Is the Most Effective • reduced or stopped use of injection mg/day to achieve optimum therapeutic
Treatment for Opiate Addiction drugs; effects of methadone. Compared to
those on lower doses, patients on higher
Methadone is a synthetic agent that • reduced risk of overdose and of doses are shown to stay in treatment
works by “occupying” the brain recep­ acquiring or transmitting diseases

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longer, use less heroin and other drugs, quarter also abuse alcohol. Studies have MMT programs also express concerns
and have lower incidence of HIV infec­ shown that 67-84% of MMT patients that they may be a magnet for crime
tion. Some patients need even higher have been infected with hepatitis C. and drug dealing and that patients will
doses for fully effective treatment. About 10 million people in the U.S. divert methadone (sell it to supplement
have co-occurring substance abuse and their income or buy or sell it to help
Studies of methadone effectiveness have
mental disorders; more than 40 percent friends in withdrawal). As a result, the
shown a dose-response relationship,
of those with addictive disorders also use of methadone to treat addiction has
with higher doses more effective in
have mental disorders. IDUs frequently been heavily regulated and strictly con-
reducing heroin use, helping patients
have unstable living situations and may trolled in this country. For example, until
stay in treatment, and reducing criminal
need multiple social services. Treatment now, MMT has been delivered only
activity. Despite compelling evidence
programs tailored to the specific needs through specially licensed clinics, called
that doses need to be determined on
of patients can respond more effectively Opioid Treatment Programs.
an individual basis, that higher doses
to these varied types of patients.
are more effective, and that doses of These regulations and controls have
60-120 mg/day are required for most Continued use of heroin, cocaine, alcohol, and meant that MMT programs have had
patients, some clinics administer fixed other drugs limited flexibility and ability to respond
doses to all patients and provide less to the needs of patients, including in
It is relatively common for MMT
than optimal doses. such key areas as dose and length of
patients to continue using heroin, other
treatment. The regulations also have
Length of treatment drugs such as cocaine or marijuana, and
limited the number of physicians who
alcohol after admission to treatment.
Studies have shown that good outcomes are available to treat heroin addiction
This reflects the long history of use,
from substance abuse treatment are and the settings and locations in which
the complexity of patients’ situations
unequivocally contingent on adequate treatment can occur.
and reasons for using drugs, and the
length of treatment. A research-based
biological basis of addiction. Many The change
guide on the principles of substance
patients in treatment do not have
abuse treatment, released in 1999 by In May 2001, the U.S. Department of
complete control over their addictions
the National Institute on Drug Abuse Health and Human Services (DHHS)
at all times. Realistic expectations of
(NIDA), notes that “For methadone announced a new system for regulating
treatment reflect the understanding that
maintenance, 12 months of treatment is and monitoring MMT. Under this new
recovery is a day-to-day process with
the minimum, and some opiate-addicted system, oversight responsibility for MMT
occasional relapses.
individuals will continue to benefit from in the United States shifted from the
methadone maintenance treatment over The Regulation and Administration Food and Drug Administration (FDA)
a period of years.” Despite this fact, the of MMT has Undergone a Radical to the Substance Abuse and Mental
majority of MMT patients leave before Change Health Services Administration’s Center
1 year, either because they drop out, the for Substance Abuse Treatment (CSAT).
clinic encourages them to leave, or they The context for change
This new system represents a fundamental
are discharged for not complying with Despite 30 years of experience and change in the approach to substance
program regulations. Most of those widespread acceptance by addiction abuse treatment and in the federal gov­
who discontinue MMT later relapse to specialists and health agencies, MMT ernment’s role in ensuring effective and
heroin use. This illustrates the difficulty has sometimes been publicly controversial accountable MMT programs. It relies
of the addiction recovery process and in the U.S. and other countries. Critics on accreditation of MMT programs
the fact that individuals may need mul­ have cited the belief that methadone by independent organizations and states,
tiple episodes of treatment over time. treatment merely substitutes one addiction in accordance with treatment standards
The need to tailor treatment to subgroups of for another and that achieving a drug- that have been developed by CSAT over
IDUs and to individual patients free state is the only valid treatment the last 10 years.
goal. Misunderstandings about the
IDUs come to MMT with a broad nature of drug addiction (not seeing These standards reflect current knowledge
range of issues and problems in addition it as a biomedical condition) are part about the nature of opiate addiction as
to their drug addiction. For example, of the reason why MMT has sometimes a chronic brain disease and the principles
about 40 percent of patients entering been met with limited acceptance by underlying effective long-term, compre­
methadone treatment use cocaine communities, health care providers, and hensive treatment. The standards are
or crack as well as heroin; perhaps a the public. Critics opposed to expanding based on “best practice guidelines” and

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emphasize improving quality of care in • Preventing Blood-borne Infections Among Bellin E, Wesson J, Tomasino V, et al.
areas such as individualized treatment Injection Drug Users: A Comprehensive High dose methadone reduced criminal
planning, increased medical supervision, Approach, which provides extensive recidivism in opiate addicts. Addiction
and assessment of patients. The new background information on HIV Research 1999;7(1):19-29.
system continues to accommodate com­ and viral hepatitis infection in IDUs
Center for Substance Abuse Treatment.
munity concerns, however, by retaining and the legal, social, and policy
State methadone treatment guidelines.
regulations that are designed to reduce environment, and describes strategies
Rockville (MD): CSAT, SAMHSA.
diversion of methadone. and principles of a comprehensive
Treatment Improvement Protocol (TIP)
approach to addressing these issues.
The designers of this new approach Series; TIP#1. DHHS Publication No.
believe that shifting to an accreditation • Interventions to Increase IDUs’ Access to (SMA)93-1991; 1993.
approach will significantly improve care Sterile Syringes, a series of six fact sheets. www.samhsa.gov/centers/csat/csat.html
for IDUs by: (click on the Treatment Improvement
• Drug Use, HIV, and the Criminal Justice
• improving access to and quality of Exchange icon and find CSAT TIPs
System, a series of eight fact sheets.
MMT programs; under Documents)
Visit these websites: D’Aunno T, Folz-Murphy N, Lin X.
• allowing for increased professional
discretion and medical judgment in • The Substance Abuse and Mental Changes in methadone treatment
designing treatment plans based on Health Services Administration, practices: results from a panel study,
individual needs, especially in managing to learn more about the new federal 1988-1995. American Journal of Drug
methadone doses and length of treat­ regulations governing methadone and Alcohol Abuse 1999;25(4):681-699.
ment, and whether withdrawal from treatment programs: www.samhsa.gov/
D’Aunno T, Vaughn TE. Variations in
medication is possible or desirable; news/news.html (click on Archives of
methadone treatment practices. Results
News Releases and scroll down to
• helping to move MMT closer to the from a national study. JAMA
the two May 18, 2001 releases)
mainstream of health care practice (this 1992;267(2):253-258.
increase in the range of settings may • The Addiction Treatment Forum,
Fiellin DA, O’Connor PG, Chawarski
increase MMT in physicians’ offices which publishes newsletters and other
M, et al. Methadone maintenance in
and increase interest by hospitals and information on substance abuse and
primary care: a randomized controlled
HMOs in providing these services); addiction research, therapies, news:
trial. JAMA 2001;286(14):1764-1765.
www.atforum.com/
• improving oversight and accountability Hser Y-I, Hoffman V, Grella CE, Anglin
and helping to promote state-of-the- • The American Methadone Treatment
MD. A 33-year follow-up of narcotics
art treatment services; and Association: www.americanmethadone.org/
addicts. Archives of General Psychiatry
• enhancing patient rights and patient See the October/November 2000 and 2001;58:503-508.
responsibilities. January 2001 issues of the Mt. Sinai National Institutes of Health. Effective
Journal of Medicine. The 14 papers in medical treatment of opiate addiction.
To Learn More About This Topic these two theme issues focus on a wide NIH Consensus Statement Online.
range of issues related to methadone Bethesda (MD): NIH; 1997, Nov 17-
Read the overview fact sheet in this
maintenance treatment and its impact 19;15(6):1-38. http://odp.od.nih.gov/con­
series on drug users and substance abuse
on IDUs, including those infected sensus/cons/108/108_intro.htm
treatment – “Substance Abuse Treatment
with HIV or hepatitis C. Mt. Sinai
for Injection Drug Users: A Strategy National Institute on Drug Abuse
Journal of Medicine 2000;67(5&6)
with Many Benefits.” It provides basic (NIDA). Buprenorphine update:
www.mssm.edu/msjournal/67/6756.shtml
information, links to the other fact questions and answers. Bethesda
and 2001;68(1)
sheets in this series, and links to other (MD): NIDA; 2001.
www.mssm.edu/msjournal/68/681.shtml
useful information (both print and web). http://165.112.78.61/Bupupdate.html
Check out these sources of information:
Visit websites of the Centers for National Institute on Drug Abuse
Disease Control and Prevention Ball JC, Ross A. The effectiveness of (NIDA). Principles of drug addiction
(www.cdc.gov/idu) and the Academy for methadone maintenance treatment. treatment: a research-based guide.
Educational Development (www.health­ New York: Springer-Verlag; 1991. Rockville (MD): NIDA; 1999. NIH
strategies.org/pubs/publications.htm) Publication No. 99-4180. http://165.
for these and related materials: 112.78.61/PODAT/ PODATindex.html

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Novick DM. The impact of hepatitis C Sees KL, Delucchi KL, Masson C, et al. Strain EC, Stitzer ML, Liebson IA,
virus infection on methadone maintenance Methadone maintenance vs. 180-day Bigelow GE. Dose-response effects of
treatment. Mount Sinai Journal of Medicine psychosocially enriched detoxification methadone in the treatment of opioid
2000; 67(5&6): 437-443. for treatment of opioid dependence: a dependence. Annals of Internal Medicine
randomized controlled trial. JAMA 1993;(119):23-27.
Novick DM, Joseph H. Medical main­
2000;283(10):1303-1310.
tenance: the treatment of chronic opiate Ward J, Hall W , Mattick RP. Role of
dependence in general medical practice. Sorensen JL, Copeland AL. Drug abuse maintenance treatment in opioid
Journal of Substance Abuse Treatment treatment as an HIV prevention strategy: dependence. Lancet
1991;8(4):233-239. a review. Drug and Alcohol Dependence 1999;353(9148):221-226.
2000;59(1):17-31.
Robles E, Miller FB, Gilmore-Thomas Weinrich M, Stuart M. Provision of
KK, McMillan DE. Implementation of Strain EC, Bigelow GE, Liebson IA, methadone treatment in primary care
a clinic policy of client-regulated Stitzer ML. Moderate- vs. high-dose medical practices: review of the Scottish
methadone dosing. Journal of Substance methadone in the treatment of opioid experience and implications for U.S.
Abuse Treatment 2001;20(3):225-230. dependence: a randomized trial. JAMA policy. JAMA 2000;283(10):1343-1348.
1999;281(11):1000-1005.

Produced by the Academy for Educational Development, with funding from CDC.

Department of Health and Human Services

http://www.cdc.gov/idu

Through the Academy for Educational Development (AED), IDU-related technical assistance is available
to health departments funded by CDC to conduct HIV prevention and to HIV prevention community planning groups (CPGs).
For more information, contact your CDC HIV prevention project officer at 404-639-5230 or AED at (202) 884-8952.

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