Archival Content: 1999-2005
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 and Public Health Problem
It is estimated that at least 980,000 people in the United States are currently addicted to heroin and other opiates (such as oxycontin, dilaudid, and hydrocone). They risk premature death and often suffer from HIV, hepatitis B or C, sexually transmitted disease (STDs), liver disease from alcohol abuse, and other physical and mental health problems. It is estimated that 5,000-10,000 IDUs die of drug overdoses every year. Many are involved with the criminal justice system.
A 1997 National Institutes of Health (NIH) report estimated the financial costs of untreated opiate addiction at $20 billion per year. These costs, combined with the social costs of destroyed families, destabilized communities, increased crime, increased disease transmission, and increased health care costs, mean that opiate addiction is a major problem for affected individuals and society.
Methadone Maintenance Treatment Is the Most Effective Treatment for Opiate Addiction
Methadone is a synthetic agent that works by "occupying" the brain receptor sites affected by heroin and other opiates. Methadone:
Methadone maintenance treatment, a program in which addicted individuals receive daily doses of methadone, was initially developed during the 1960s as part of a broad, multicomponent treatment program that also emphasized resocialization and vocational training.
Methadone maintenance treatment has important benefits for addicted individuals and for society.
These benefits include:
Using commonly accepted criteria for medical interventions, several studies have also shown that MMT is extremely cost-effective.
Key Issues in Effective Methadone Maintenance Treatment
Most patients require a dose of 60-120 mg/day to achieve optimum therapeutic effects of methadone. Compared to those on lower doses, patients on higher doses are shown to stay in treatment longer, use less heroin and other drugs, and have lower incidence of HIV infection. Some patients need even higher doses for fully effective treatment.
Studies of methadone effectiveness have shown a dose-response relationship, with higher doses more effective in reducing heroin use, helping patients stay in treatment, and reducing criminal activity. Despite compelling evidence that doses need to be determined on an individual basis, that higher doses are more effective, and that doses of 60-120 mg/day are required for most patients, some clinics administer fixed doses to all patients and provide less than optimal doses.
Length of treatment
Studies have shown that good outcomes from substance abuse treatment are unequivocally contingent on adequate length of treatment. A research-based guide on the principles of substance abuse treatment, released in 1999 by the National Institute on Drug Abuse (NIDA), notes that "For methadone maintenance, 12 months of treatment is the minimum, and some opiate-addicted individuals will continue to benefit from methadone maintenance treatment over a period of years." Despite this fact, the majority of MMT patients leave before 1 year, either because they drop out, the clinic encourages them to leave, or they are discharged for not complying with program regulations. Most of those who discontinue MMT later relapse to heroin use. This illustrates the difficulty of the addiction recovery process and the fact that individuals may need multiple episodes of treatment over time.
The need to tailor treatment to subgroups of IDUs and to individual patients
IDUs come to MMT with a broad range of issues and problems in addition to their drug addiction. For example, about 40 percent of patients entering methadone treatment use cocaine or crack as well as heroin; perhaps a quarter also abuse alcohol. Studies have shown that 67-84% of MMT patients have been infected with hepatitis C. About 10 million people in the U.S. have co-occurring substance abuse and mental disorders; more than 40 percent of those with addictive disorders also have mental disorders. IDUs frequently have unstable living situations and may need multiple social services. Treatment programs tailored to the specific needs of patients can respond more effectively to these varied types of patients.
Continued use of heroin, cocaine, alcohol, and other drugs
It is relatively common for MMT patients to continue using heroin, other drugs such as cocaine or marijuana, and alcohol after admission to treatment. This reflects the long history of use, the complexity of patients' situations and reasons for using drugs, and the biological basis of addiction. Many patients in treatment do not have complete control over their addictions at all times. Realistic expectations of treatment reflect the understanding that recovery is a day-to-day process with occasional relapses.
The Regulation and Administration of MMT has Undergone a Radical Change
The context for change
Despite 30 years of experience and widespread acceptance by addiction specialists and health agencies, MMT has sometimes been publicly controversial in the U.S. and other countries. Critics have cited the belief that methadone treatment merely substitutes one addiction for another and that achieving a drug-free state is the only valid treatment goal. Misunderstandings about the nature of drug addiction (not seeing it as a biomedical condition) are part of the reason why MMT has sometimes been met with limited acceptance by communities, health care providers, and the public. Critics opposed to expanding MMT programs also express concerns that they may be a magnet for crime and drug dealing and that patients will divert methadone (sell it to supplement their income or buy or sell it to help friends in withdrawal). As a result, the use of methadone to treat addiction has been heavily regulated and strictly controlled in this country. For example, until now, MMT has been delivered only through specially licensed clinics, called Opioid Treatment Programs.
These regulations and controls have meant that MMT programs have had limited flexibility and ability to respond to the needs of patients, including in such key areas as dose and length of treatment. The regulations also have limited the number of physicians who are available to treat heroin addiction and the settings and locations in which treatment can occur.
In May 2001, the U.S. Department of Health and Human Services (DHHS) announced a new system for regulating and monitoring MMT. Under this new system, oversight responsibility for MMT in the United States shifted from the Food and Drug Administration (FDA) to the Substance Abuse and Mental Health Services Administration's Center for Substance Abuse Treatment (CSAT).
This new system represents a fundamental change in the approach to substance abuse treatment and in the federal government's role in ensuring effective and accountable MMT programs. It relies on accreditation of MMT programs by independent organizations and states, in accordance with treatment standards that have been developed by CSAT over the last 10 years.
These standards reflect current knowledge about the nature of opiate addiction as a chronic brain disease and the principles underlying effective long-term, comprehensive treatment. The standards are based on "best practice guidelines" and emphasize improving quality of care in areas such as individualized treatment planning, increased medical supervision, and assessment of patients. The new system continues to accommodate community concerns, however, by retaining regulations that are designed to reduce diversion of methadone.
The designers of this new approach believe that shifting to an accreditation approach will significantly improve care for IDUs by:
To Learn More About This Topic
Read the overview fact sheet in this series on drug users and substance abuse treatment - "Substance Abuse Treatment for Injection Drug Users: A Strategy with Many Benefits." It provides basic information, links to the other fact sheets in this series, and links to other useful information (both print and web).
Visit these websites:
See the October/November 2000 and January 2001 issues of the Mt. Sinai Journal of Medicine. The 14 papers in these two theme issues focus on a wide range of issues related to methadone maintenance treatment and its impact on IDUs, including those infected with HIV or hepatitis C. Mt. Sinai Journal of Medicine 2000;67(5&6) and 2001;68(1)
Check out these sources of information:
Ball JC, Ross A. The effectiveness of methadone maintenance treatment. New York: Springer-Verlag; 1991.
Bellin E, Wesson J, Tomasino V, et al. High dose methadone reduced criminal recidivism in opiate addicts. Addiction Research 1999;7(1):19-29.
Center for Substance Abuse Treatment. State methadone treatment guidelines. Rockville (MD): CSAT, SAMHSA. Treatment Improvement Protocol (TIP) Series; TIP#1. DHHS Publication No. (SMA)93-1991; 1993. (click on the Treatment Improvement Exchange icon and find CSAT TIPs under Documents)
D'Aunno T, Folz-Murphy N, Lin X. Changes in methadone treatment practices: results from a panel study, 1988-1995. American Journal of Drug and Alcohol Abuse 1999;25(4):681-699.
D'Aunno T, Vaughn TE. Variations in methadone treatment practices. Results from a national study. JAMA 1992;267(2):253-258.
Fiellin DA, O'Connor PG, Chawarski M, et al. Methadone maintenance in primary care: a randomized controlled trial. JAMA 2001;286(14):1764-1765.
Hser Y-I, Hoffman V, Grella CE, Anglin MD. A 33-year follow-up of narcotics addicts. Archives of General Psychiatry 2001;58:503-508.
National Institutes of Health. Effective medical treatment of opiate addiction. NIH Consensus Statement Online. Bethesda (MD): NIH; 1997, Nov 17-19;15(6):1-38.
National Institute on Drug Abuse (NIDA). Buprenorphine update: questions and answers. Bethesda (MD): NIDA; 2001.
National Institute on Drug Abuse (NIDA). Principles of drug addiction treatment: a research-based guide. Rockville (MD): NIDA; 1999. NIH Publication No. 99-4180.
Novick DM. The impact of hepatitis C virus infection on methadone maintenance treatment. (36 KB, 7 pages) Mount Sinai Journal of Medicine 2000; 67(5&6): 437-443.
Novick DM, Joseph H. Medical maintenance: the treatment of chronic opiate dependence in general medical practice. Journal of Substance Abuse Treatment 1991;8(4):233-239.
Robles E, Miller FB, Gilmore-Thomas KK, McMillan DE. Implementation of a clinic policy of client-regulated methadone dosing. Journal of Substance Abuse Treatment 2001;20(3):225-230.
Sees KL, Delucchi KL, Masson C, et al. Methadone maintenance vs. 180-day psychosocially enriched detoxification for treatment of opioid dependence: a randomized controlled trial. JAMA 2000;283(10):1303-1310.
Sorensen JL, Copeland AL. Drug abuse treatment as an HIV prevention strategy: a review. Drug and Alcohol Dependence 2000;59(1):17-31.
Strain EC, Bigelow GE, Liebson IA, Stitzer ML. Moderate- vs. high-dose methadone in the treatment of opioid dependence: a randomized trial. JAMA 1999;281(11):1000-1005.
Strain EC, Stitzer ML, Liebson IA, Bigelow GE. Dose-response effects of methadone in the treatment of opioid dependence. Annals of Internal Medicine 1993;(119):23-27.
Ward J, Hall W, Mattick RP. Role of maintenance treatment in opioid dependence. Lancet 1999;353(9148):221-226.
Weinrich M, Stuart M. Provision of methadone treatment in primary care medical practices: review of the Scottish experience and implications for U.S. policy. JAMA 2000;283(10):1343-1348.
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