The following information is the transcript of a phone interview conducted in October 2016 with Dr. Evan Baldwin.
Methadone is a medication that was created around 80 years ago. The original goal of the medication was not necessarily to be a treatment for opioid dependence, but, as it turned out, it is very useful for that purpose.
In order to understand how methadone is used for treatment of opioid dependence, there are some words you need to understand. One is opioid dependence, which is a medical diagnosis. It basically means your body has gotten so used to the opioids you have been taking, be that pain pills or heroin or what have you, that it has developed a tolerance such that if you stop taking them you will go into withdrawal. So that’s opioid dependence in a nutshell.
There’s another important term, and it is opioid abuse. This is a behavioral diagnosis which basically describes someone not using opiates in an appropriate manner. Perhaps they’re taking more than they’re prescribed, or they are taking medication they are not prescribed, or they’re taking illicit substances such as heroin or illicit Fentanyl, etc.
Many patients who begin to abuse opiates, and even patients who are legitimately prescribed them, develop opioid dependence. A significant root of the opioid problem lies with physiological opioid dependence. It’s the human body needing opiates on a regular basis to keep it from going into withdrawal.
The withdrawal symptoms experienced from specific drugs differs from one to another. Specifically, with opiates, it commonly causes severe flu-like symptoms. You can imagine the worst flu you’ve ever had in your life, and that’s what it can be like if a heroin user or a pain pill dependent person stops taking them. So it creates this cycle of abuse that is difficult to get out of because, well, it’s often quite terrible. Opioid withdrawal symptoms can keep someone from carrying out their normal everyday life functions. Meaning it can be tough to be withdrawing from heroin or pain pills and still continue to go to your job, still continue to take care of your kids, or whatever other life obligations that you have. So although you may not have intended to be dependent on opioids, once you are it can be a very difficult cycle to exit.
We’ve seen over the last several decades that opioid dependence has continued to rise and rise. The reason for that is multi-factorial. One is a growing and aging population, and two is more opiates have been disseminated into the population through the treatment of pain and the development of new medications to treat pain. Legitimate pain should be treated, and opiates are certainly a useful adjunct for that purpose; however, they can have untoward consequences. As these medications have gained popularity, the amount of abuse and dependence in the population has likewise increased.
Furthermore, the aging population in the United States has contributed to that problem. As many within this demographic start to develop chronic pain, it has led to lots of pain medication prescriptions. Again, this not to say that treating pain with opioids is bad, but the more opioids you have out in the community, the higher the likelihood for abuse and dependence.
To get back to methadone. Methadone is a medication that was created for pain. It was created decades ago in Germany actually, for use with their military. What they created was a medication which binds opioid receptors in your body strongly and for a long period of time.
Methadone is useful for treatment of opioid dependence for a number of reasons.
So there’s a couple of different pharmaco-dynamic and pharmaco-kinetic terms to understand. One is called binding affinity, which means how strongly does a medication bind to its receptors in your body. And it’s different between medications, even for very similar ones. Methadone has a high binding affinity which means that it will bind stronger than many other opioids.
Another term is half-life, which is a measure of how long a medication is present in your body. More specifically, a half-life is how long it takes your body to reduce the amount of medication by 50%. That can be hours. It can also be minutes. For example, Fentanyl is extremely short-acting. Whereas at the other end of the spectrum, methadone is extremely long-acting, and that property is one which helps make it useful for treatment of opioid dependence.
If you are using heroin, the half-life of that is very short. Which means when you use it, after it hits your system, it’s very rapidly eliminated. Because of this, it’s something you have to repeatedly dose to stay out of withdrawals, which is why many heroin addicts inject multiple times per day. So you can see how it becomes a very consuming problem.
Methadone is useful for treatment of opioid dependence for a number of reasons. Two important reasons are its long half-life and its strong opioid receptor binding affinity. Because methadone has such a long half-life it can be dosed only once per day. This eliminates the need to spend your entire day figuring out how you’re going to get opiates into your system. After a small number of days of consistent methadone dosing, you get to a fairly constant blood level of the medication, which eliminates the likelihood of going into withdrawals and eliminates the need to run around all day to find drugs.
Someone who uses heroin usually does not get a high feeling with appropriately dosed methadone. A reason for this is that they have such high tolerance. If I, myself, being opiate naïve, took methadone, I would experience very profound and dangerous effects. However, people who are dependent on opioids tend to lose much of the euphoric effects as they develop tolerance.
You may have heard addicts say, “Look, I’m not using to get high. I’m just trying to get well.” And it’s true for many. Often they aren’t looking to get high. They are just looking to avoid withdrawal. The heroin or the pain pills they’re using every day may not be because they are trying to get high, they may just be trying to get by – so they don’t go into withdrawals, so they can they can function more normally. In fact, you would be surprised at the number of people in any community who are carrying out normal life functions with opiates on board, be it methadone or pain pills or heroin or what have you.
As people discovered that methadone was very useful for treatment of opioid dependence, the idea of the methadone clinic was created. The technical term for a methadone clinic is called an opioid treatment program, and there are many hundreds all over the United States.
In a sentence, an opioid treatment program is a very highly-regulated outpatient clinic setting where patients receive treatment for opioid use disorders, not only through opioid replacement medication therapy, but also a structured environment where they participate in counseling, physician medical services, socioeconomic guidance and peer support.
But “methadone clinic” is a phrase which has a branding problem. It has become a term which is often associated with negative feelings and imagery of a seedy and unsafe environment. In reality, clinics are a very structured environment and are actually very safe. They are responsible for the largest percentage of all the effective opioid addiction treatment in the United States and have been for decades. There’s no medication that has been better researched or better proven than methadone for treatment for opioid dependence. There are also newer medications like buprenorphine or naltrexone. Those are indeed good, but they certainly don’t have the breadth of research and support that methadone does.
Methadone administered for opioid dependence is done exclusively through OTPs and within that setting it’s safe for patients and safe for the community. In fact, OTPs are very useful for their community – they provide important treatment and reduce the crime in a community. There are multiple studies over the past several decades which illustrate for every dollar invested in substance abuse treatment, you save multiple dollars in future expenditures on things like law enforcement, jailing, etc.
OTP licensing is demanding. The clinic and physicians have to be certified by the DEA, the clinic and physicians have to be certified by the Board of Pharmacy, the clinic has to be approved and inspected by the State Opioid Treatment Authority which is a government program that every state has which oversees the integrity of all the clinics, the clinic has to be certified Federally by SAMHSA and CSAT under HHS. Then, on top of that, a clinic has a third-party accrediting body that looks at the program comprehensively – medical practices, therapy practices, pharmacy practices, employment practices, safety plans, emergency preparedness, the list goes on and on. So maintaining an OTP is an onerous process, but it helps keep the system clean. People sometimes think methadone clinics are just legal drug dealers, but it’s not true. More than likely, it’s an honest team of people busting their ass to keep their clinic in line with regulations and provide a much needed service to a largely underserved population.
Despite this, there are people, even sometimes physicians, who are opposed to medication-assisted treatment. Sometimes they say, “You’re not treating them. You’re just giving them another drug.” In my opinion, statements like these show a lack of understanding about opioid dependence and lack of familiarity with treatment of opioid use disorders. While it is true that OTPs administer a replacement opioid as part of treatment, doing so allows the patient to exchange dangerous and illegal opioids with a safe, controlled, legal alternative. This exchange provides the stability to put the brakes on all the things in their life that have fallen apart, take a deep breath, and then utilize OTP counselors and physicians to develop a plan for treating their addiction and rebuilding their life.
Treatment with methadone is a fairly straightforward process. A patient comes to the OTP and, once proven to be truly opioid dependent and an appropriate candidate, is titrated up from a very low dose to their stable dose. Each person’s stable dose is different and depends on many factors, but is between 60 and 120mg per day for a large percentage of patients. Once a person is at a stable dose, they truly have an opportunity to take a deep breath and address their addiction without the fear of withdrawal, without the daily need to find money for opioids, and without the often chaotic lifestyle of an opioid dependent person.
Once a patient is on a stable dose and has had the opportunity to address the psychosocial underpinnings of their addiction, an OTP will often start a slow titration off of the opioid replacement medication with the goal of freeing them from the need for opioids completely.
However, for a subset of patients, opioid replacement therapy can become lifelong. In my practice, I always attempt to wean stable patients down on their medication, and most will give it a try. But sometimes patients refuse, or fail the weaning process. For these folks, I tend to respect their decision and maintain them on replacement therapy provided that they are continuing to do well. It’s tough to decide to force a patient to titrate off when they tell you “I don’t think you understand. I was addicted to heroin. It ruined my life. But the last five years where I’ve been on methadone I can live. Everything’s better. I don’t care that I’ve gotta dose with methadone every day. I feel normal. What difference does it make?” And for them I don’t argue. I don’t kick people off in situations like these. I think that’s a patient autonomy principal you need to respect, assuming doing so is medically safe.
That’s not to say there aren’t patients who misuse OTP treatment. One way this happens is they stay at a relatively low dose of methadone so they can still continue to get high on top of it. There is certainly a subset of patients who do this. They get on methadone almost as an insurance policy against going into withdrawal. But at the same time, it is not entirely useless because they still have one foot in the pool. And they’re involved with the clinic. They’re still attending counseling and eventually they’ll jump in. They’ll say, “Look I gotta stop doing this, dealing with all this bullshit. I’m really gonna take treatment seriously.” So even people who misuse OTP treatment are receiving some benefit in the form of harm reduction. Even if they’re still using drugs occasionally or on weekends or whatever, if you reduce the number of times in a week that they’re using at all, well then you reduce the likelihood of overdose. You reduce the likelihood of the transmission of Hepatitis or HIV. You reduce the amount of money that goes to drug cartels. You reduce the amount of stealing and prostituting and things people do to get money to buy drugs. Even those who aren’t fully invested in treatment do still see some benefit.
It’s also important people understand the cost of methadone treatment through an OTP. Suffice to say it is relatively inexpensive. The medication itself costs less than a dollar a day, and even once you add in the physician services, counseling, pharmacy, regulatory demands, etc., the total daily cost across the US is generally only between $12 and $18 per day. This cost is essentially insignificant when you weigh it against the daily costs of opioid dependence. It is not uncommon for my patients to come to treatment spending $40-200 daily on illicit opioids , not to mention the incredible societal costs.
I touched on this earlier, but it’s also important people understand the regulatory structure OTPs must adhere to. Every opioid treatment program has to comply with the federal guidelines, which are lengthy and comprehensive. They go into great detail about all the things an OTP has to offer in addition to the medication. For example, counseling a minimum number of times and hours per month, socioeconomic support, testing and reporting for Hepatitis and HIV and syphilis, physician visits, toxicology testing, etc. So there’s a lot of really good mandatory ancillary services which are provided by the OTP that would otherwise be unlikely to be sought out by this particular patient population. Furthermore, OTPs serve an important role in identifying those that are at risk for other health problems and referring them to appropriate treatment. So if anyone thinks that methadone clinics just dispense free drugs certainly does not really understand the value.
Addiction is a medical problem like any other. It is not a disease of moral fiber. It’s a disease of physiology – both mind and body.
Stigma is one of the biggest challenges facing these individuals. Patients tell me they’ve had a secret pain pill dependence for a decade that their spouse doesn’t know about, and they have been too ashamed to seek help. Professionals tell me they haven’t sought treatment because they are fearful it will end their career. Addiction carries stigma that other medical disorders do not. Would a spouse leave a marriage if they found out about a secret thyroid disorder? Of course not.
Addiction is a medical problem like any other. It is not a disease of moral fiber. It’s a disease of physiology – both mind and body. Maybe the day someone started taking heroin they made a bad choice, but certainly their daily choice to continue to use ten years down the road is not because they are immoral. It’s because they have created an untenable situation within their own physiology that is very difficult to overcome.
Another thing, too, addiction has genetic underpinnings. It’s an emerging part of the addiction field that is really interesting. There really is a genetic link between family members to have a propensity for the development of addictions. Just as a child tends to look like their parents physically, their brains tend to operate like their parents. So neural pathways and chemistry that lend a person to a higher propensity for addiction can be inherited.
That’s why you see these people that are like, “I got in a car accident. I took pain pills for two weeks, and, my God, I could never get off them.” You think to yourself how is that possible? But it’s just different for some people. Whereas others get in a car accident, they have the same injuries, and they’re like “God, I took pain pills for two weeks, and it was awful. I couldn’t wait to get off them. I hated the way they made me feel. I hated being on it. I just switched to Tylenol as quickly I as could.”
This is not to say that all addiction is inherited, and children of parents with addictions are doomed to the same fate. It is just important to consider genetic factors among the many others, such as socioeconomic issues, potential behavioral or psychiatric problems, cultural influences, etc.
All of these things should be considered given the scope of the issue now. Drug overdoses are now as big of a contributor to mortality in the United States as are motor vehicle accidents. The amount of effort that is put into vehicle safety, seatbelt laws, etc., should also be given to drug abuse because it’s killing just as many people.
In my opinion, one of the most important advances in the treatment of addiction in the last decade has been the expansion of healthcare coverage and the inclusion of these behavioral health services. Now, more patients have insurance to help pay the costs, and providers have a way of getting paid to provide the services – it’s as simple as that. If anything, insurance companies should be very eager to get their patients into medication assisted treatment because otherwise they’re going to end up paying for hospital bills when they get their next abscess, Hepatitis C treatment, sepsis, overdose, etc. The actuaries are coming around at these companies, sometimes they’re just a little bit behind. In the last five to ten years, a lot of states have added methadone treatment to their Medicaid treatment. In the state of New Mexico it was about three or four years ago. Before that, it was entirely a cash model. That’s the biggest thing for treatment that has occurred, at least for opioids, in the last decade. The number of patients on methadone have dramatically increased nationally due to that one thing alone.
The last thing I want to tell you about is a push we have. It’s the way things really need to be in the United States. And that is widespread medication assisted treatment within correctional facilities.
Our company, Recovery Services of New Mexico, about six years ago, founded a privately contracted methadone maintenance treatment program within our county jail. It had not been done before by a private company to our knowledge. At that time, there had only been a handful of government run programs within jails and prisons in the US. People thought it was the craziest thing at first, but it has been proven through a study by the University of New Mexico to be valuable at reducing recidivism and improving treatment adherence after release. It’s really what needs to happen in every jail. They need to be able to continue people on methadone and also use it as a point to start people on methadone. That is, in my opinion, the next big change we need in the US for treatment of drug addiction.
