Many people view methadone and buprenorphine as merely “substituting one addiction for another” because the medications are opioid based. In truth, they are fundamentally different from short-acting opioids such as heroin or fentanyl. Heroin goes right to the brain and narcotizes the individual, causing sedation. In contrast, as a SAMHSA fact sheet states—
Methadone does not create a pleasurable or euphoric feeling; rather it relieves physiological opioid craving … and normalizes the body’s metabolic and hormonal functioning that were impaired by the use of heroin or other opioids (SAMHSA, 2003).
The same is true for buprenorphine when used by knowledgeable practitioners. The FDA approved these medications after years of rigorous scientific research demonstrated that they are beneficial in the treatment of opioid use disorder.
People often mistakenly believe that a lower dose of methadone and buprenorphine is preferable to a higher dose. The literature and clinical practice have long established therapeutic dosage ranges for methadone and buprenorphine. The key is to prescribe the appropriate dosage based on the presenting needs of the individual. The principle is prescribing an effective dose, not a low dose. The use of substandard dosages is countertherapeutic since the patient will continue to use opioids if the maintenance dosage is too low. The dose for injectable naltrexone is standard.
Dosing, however, is an individualized medical decision. For example, most patients require a methadone dose of 60-120 milligrams per day; studies show that patients on higher doses stay in treatment longer and use less heroin and other drugs than those on lower doses. Pre-conceived beliefs, without scientific basis, that lower doses are preferable, detract from the potential value of MAT. (Center for Court Innovation/Legal Action Center – 2015)
Length of time in treatment is another often misunderstood aspect of MAT. As stated by NIDA, the duration of treatment typically depends on the patient’s presenting problems and needs. It is generally accepted that a minimum of 12 months is required for methadone maintenance to be effective (NIDA, 2009). As stated in the SAMHSA fact sheet, “When taken as prescribed, long-term administration of methadone causes no adverse effects to the heart, lungs, liver, kidneys, blood, bones, brain, or other vital body organs” (SAMHSA, 2003).
Longer treatment is typically recommended. Drs. Stephen Magura and Andrew Rosenblum wrote an influential article in 2001 focusing on duration of treatment with regard to methadone.
The detrimental consequences of leaving methadone treatment are dramatically indicated by greatly increased death rates following discharge. Until more is learned about how to improve post-detoxification outcomes for methadone patients, treatment providers and regulatory/funding agencies should be very cautious about imposing disincentives and structural barriers to discourage or impede long term opioid replacement therapy (Magura & Rosenblum, 2001).
Duration of time in treatment is therefore best determined by the healthcare provider and patient.
Many have reported on the diversion of methadone and buprenorphine (e.g., Lavonas, et al., 2014; Bazazi, Yokell, Fu, Rich, & Zaller, 2011; Sokya, 2014). Five national reports (GAO, 2009; U.S. Department of Justice, 2007; SAMHSA, 2010, 2007, 2004) have stated, however, that most methadone-related diversion is the result of methadone prescribed by general medical practitioners to treat pain, and not by opioid treatment programs. Federal and State regulations (e.g., SAMHSA, 2001) govern how much methadone can be provided to a patient—depending on success in treatment—and guide clinical decisions in the Opioid Treatment Program. Justice agencies have controls in place to minimize diversion of buprenorphine and methadone. Accordingly, such take-home medication is under tight regulatory oversight.
Criminal justice agencies can put controls in place to minimize diversion of buprenorphine and methadone. Successful models in the drug court context are explained in “Medication-Assisted Treatment in Drug Courts: Recommended Strategies,” a guide published by the New York Office of Court Administration, Center for Court Innovation, and the Legal Action Center.
There is also discussion about whether an individual is in true “recovery” when taking these addiction medications. William White and Lisa Mojer-Torres wrote:
For stabilized methadone maintenance patients, continued methadone maintenance or completed tapering and sustained recovery without medication support represent varieties/styles of recovery experience and matters of personal choice, not the boundary between and point of passage from the status of addiction to the status of recovery (White & Torres, 2010)
This paper by White and Mojer-Torres discusses the value of Medication-Supported Recovery for opioid use disorder for people who choose to use medication as part of sustaining their continued health.