The Methadone Program: a continued first-line option for opioid dependence?
Opium, derived from the seemingly innocuous poppy, is an addictive but highly effective pain-relief agent. The Victorian Methadone Program has been operational since 1985 to manage individuals dependent on opioids, but its implementation has not been without contention.
Opium forms the chemical backbone for, among others, morphine, codeine, heroin, oxycodone (commonly known as Endone – a brand-name for its rapid-release version) and methadone. And up until 1903, it was freely available at grocery stores and an ingredient in Coca-Cola. However, in line with many other countries, opium has since been heavily regulated in Australia due to its addictive properties.
But today, the increased prescription of opium-derived pain medications has meant dependence is a problem for an increasing number of Australians.
“Prescription drugs are the new heroin,” says Dr Alex Wodak, president of the Australian Drug Law Reform Foundation. And indeed, whilst heroin use appears to be on the decline, the 2013 National Drug Strategy Household Survey found a significant rise in the misuse of both prescription and over-the-counter medications, with a codeine/paracetamol combination being the most commonly prescribed drug to be misused.
Accordingly, the number of individuals needing treatment for opioid dependence has almost doubled since 1998.
How does the program work?
Withdrawal from opioids—going “cold turkey”—is not life threatening, but can last up to ten days and the intensity of symptoms can often be so unpleasant that individuals are driven back to use. And in those who do relapse, the risk of overdose is higher than it was prior to withdrawal. Consequently, managing withdrawal with the use of (typically weaker and longer-acting) opium-derived drugs is considered a viable long-term alternative to immediate cessation.
Methadone, buprenorphine and naloxone are all long-acting opium-derived drugs that are used to treat patients who are dependent on heroin or opioid-based pain relief medications. Methadone is the most commonly prescribed medication of the three.
Treating opioid dependence by prescribing another opioid may seem counterintuitive, but methadone is particularly well suited to this task. Rather than ‘curing’ dependence, methadone works as substitution therapy, preventing the symptoms associated with opioid withdrawal without providing the euphoria associated with other opioid use.
This reduces not only the need for individuals to seek out drugs, but as it is administered orally instead of by injection it reduces the risk of intravenous transmission of disease. Importantly, it provides a financially viable and socially stabilising alternative to these other opioids. The dose of methadone can then be gradually reduced until the patient is no longer dependent.
An insight into the program
General Practitioner Dr Neville Leslie has been a part of the methadone program since 1993. He works in Murchison, a rural town 35km south of Shepparton, and reports that opioid dependence takes a different form in the country. In his experience, “heroin is soaked up in Melbourne”, so the patients he treats are almost entirely dependent on prescribed opioids.
Initially patients attend a pharmacy daily for their methadone dose, and once stabilised are able to pick up multiple days’ worth at once, known as “take-aways”. Dr Leslie reports that patients on the methadone program have fewer overdoses and are five times less likely to die compared with illicit opioid users.
And the downsides?
Of course, not all of the results of the program have been positive. A 2003 Cochrane review found that whilst methadone effectively reduces heroin use, it does not result in a statistically significant reduction in criminal activity. Dr Leslie concedes that in his experience it can often be difficult to wean individuals off methadone completely, but notes that there is significant variability between patients.
Dr Leslie reports that “long-term use of methadone can cause pituitary suppression, resulting in osteoporosis, low testosterone in males, and menstrual problems in females”. And It is due to these health risks that some have labelled methadone “liquid handcuffs”, arguing that the medication merely maintains opioid dependence rather than facilitating gradual freedom from the drug.
Methadone carries with it a risk of sedation and overdose in misuse, especially when used in combination with alcohol or benzodiazepines. And despite requiring patients to lock their take-aways in a cupboard, children have tragically died by overdosing on a parent or relative’s methadone. In syrup form, methadone runs the risk of being mistaken for cordial.
Additionally, social stigma continues to act as a barrier for adoption of the methadone program for both doctors and patients. A 2010 Australian Family Physician article reflected that GPs might be hesitant in treating patients with opioid dependence, feeling they lack specialist support and preoccupied with “concern about ‘that sort of patient’ in their clinic”.
How might treatment for addiction be further improved?
In Dr Leslie’s experience, “some patients do not do well on methadone”. As a means of improving the outcomes of the methadone program, he suggests safe injecting clinics could be a viable second line for treatment-resistant patients. In line with this, a meta-analysis published in the British Journal of Psychiatry found that patients treated with supervised injectable heroin had significantly lower rates of concurrent ‘street’ heroin use than individuals allocated to the control group (mostly receiving methadone maintenance treatment).
A safe injecting clinic in North Richmond has been proposed by the Victorian government, but we are yet to hear whether it will go ahead.
With an increasing dependence on opium-derived prescription medications, and growing enthusiasm for social solutions over punitive measures, the methadone program stands as a successful but less than perfect response. Whilst public concerns remain, perhaps a greater openness to new policy options may promise additional improvements to patient outcomes.
The views and opinions expressed in this article are those of the author and do not necessarily represent those of the Doctus Project.