Is methadone a miracle cure or an alternative evil?

Abstract

The medical complications of opioid addiction were described in classic articles in 1967 by Cherubin1 and Louria and colleagues.2 These authors chronicled overdoses occurring commonly with respiratory arrest, endocarditis, septic emboli, pneumonia, tetanus, malaria, hepatitis and other disorders in injection drug users in New York City. They estimated that approximately 1% of those addicted to opioids died every year as the direct result of an overdose, and that in 1964 in New York City, there were nearly 400 deaths related to opioid use.1,2 Although criminal behavior and the financial impact of providing medical care were not discussed, the implications of addiction became clear. Cherubin wrote of those who were addicted that “it is an element of their place in the world that they... have largely been ignored medically” and pleaded that “the past neglect... be reversed”.1 Almost simultaneously, as psychiatrists and law enforcement officials were failing to stem the tide of opioid addiction and its complications, the noted experts on metabolism, Dole and Nyswander, hypothesized that heroin addiction was a metabolic problem.3 As in the treatment of other diseases, pharmacotherapy was indicated, and careful titration of methadone, a long acting opioid, was the solution. Dole and Nyswander noted that methadone replacement provides two unique effects: at low doses it offers relief from withdrawal, and at higher doses methadone blocks the euphoria associated with heroin use. Quite rapidly, federally funded methadone clinics were born. Thirty years later, over 100,000 patients are enrolled in methadone maintenance programs. Karch and Stephens offer insight into the deaths of 38 patients on methadone maintenance who died in San Francisco. Rare infectious diseases such as necrotizing fasciitis are still common in addicts, and this finding may suggest a direct effect of opioids on the immune system. It was disappointing that cocaine use was detected in nearly half the people in whom methadone was detected and that other drugs, such as benzodiazepines, were also commonly used. However, although rigid criteria for defining deaths related to methadone were not specified, the authors identified only 21 cases in which methadone toxicity was the cause of death in 1 year in a large municipality. Since replacing heroin with methadone fails to cure all of the problems associated with addiction, we should ask if the objectives of methadone maintenance are being met as measured by a decrease in the number of deaths caused by opioids, a reduction in the number of addicts contracting an infectious disease, and a reduction in criminal behavior. Although there is little epidemiological data that would allow a direct comparison of mortality from methadone with mortality from heroin, a study by Caplehorn and Drummer using a cross-sectional design showed that methadone maintenance saved more than two lives for every death related to heroin in New South Wales.4 Interestingly, they noted that since most of the deaths related to methadone occurred during the first 2 weeks of treatment, enhanced monitoring of patients during this time could improve the success of the programs. Methadone maintenance was originally designed as a treatment for impatients. In the 1960s and 1970s the most common infectious disorders associated with injection drug use were endocarditis, hepatitis, and pneumonia.1,2 Recent data show that when adequate doses of methadone are used, long term maintenance is effective in preventing infection with HIV, probably resulting from the combined effects of reduced needle sharing and counseling about safe sexual practices.5 In addition, the structured environment of methadone maintenance clinics has proven to be an excellent location in which to screen for and treat tuberculosis in patients considered to be at high risk.6 Although it may be argued that the benefits of methadone maintenance are largely conferred on the individual, the prevention of criminal behavior has its greatest rewards in the community. Numerous studies show that methadone maintenance reduces criminal behavior even when participants continue to use illicit non-opioid substances.7, 8, 9, 10 Methadone is not a miracle cure. Simply providing a long acting synthetic opioid to patients who have important social, financial, and, possibly, genetic pressures to maintain their addiction cannot be expected to prevent an overdose, the misuse of other drugs, infections, and crime. The data, however, strongly show that the benefits of methadone maintenance far outweigh its costs and risks. Previously, emphasis was placed on providing the best therapeutic dose11,12; more recent data suggest that greater benefit is derived from the structured environment and the interpersonal interactions provided during counseling.13 Strong programs are needed to ensure the continued success of methadone maintenance; these programs must combine public health initiatives, patient education, job training, and social support to augment drug replacement. Only when these resources are added to the simple act of drug replacement can we gain the maximum reduction in risk from methadone maintenance.