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FAQFrequently Asked Questions (FAQs) - and Answers

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Responses to Frequently Asked Questions (FAQs) were developed by the editorial staff of Addiction Treatment Forum and made possible by an educational grant from Covidien Mallinckrodt, a manufacturer of methadone and naltrexone.

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long term effectsHealth & Nutrition During Medication-Assisted Treatment

Are There Any Long-Term Harmful Effects Of Methadone?

Methadone for treating opioid addiction provides strong benefits in reducing addiction-related physical illnesses, communicable diseases, and deaths. Typically, the death rate due to any causes in methadone-maintained patients in medication-assisted treatment (MAT) is a third to a fourth of that in untreated opioid addicts. Also, severe adverse reactions have been relatively rare in the millions of patients treated with methadone since 1964 worldwide, with many patients remaining on the medication more than 20 years. The vast majority of methadone-associated deaths are due to people using (or abusing) methadone prescribed for pain.

The effects of methadone on the health of patients in MAT have been studied very thoroughly. Mary Jeanne Kreek, MD, one of the best known researchers in the field of methadone maintenance treatment, has summed up the findings:

“The most important medical consequence of [ongoing] methadone treatment, in fact, is the marked improvement in general health and nutritional status observed in patients as compared with their status at time of admission to treatment. Most medical complications observed in methadone maintenance patients are either related to ongoing preexisting chronic disease, especially chronic liver disease, the onset of which occurred prior to entry into methadone treatment, or to coexisting new diseases or illnesses or to ongoing polydrug or alcohol use.”

In short, patients grow healthier during methadone maintenance treatment. Just how healthy depends on their condition before treatment and how they take care of themselves during treatment.

Long-term prospective studies have demonstrated that methadone is medically safe and generally without toxic reactions requiring hospitalization. Methadone’s side effects are generally mild, are most common during early days of treatment, and can be minimized. Maintenance on an adequate methadone dose does not affect a person’s mental ability, or ability to drive motor vehicles or perform work tasks; this is true only if the patient has been stabilized on methadone and does not use or abuse other drugs, including alcohol and benzodiazepines. Clinical evidence suggests that most physical complaints associated with methadone treatment can be attributed to: 1) patients’ abuse of other substances while in treatment; 2) normal opioid withdrawal symptoms, possibly associated with inadequate methadone dose; 3) adjustment to methadone dose changes; or 4) the influence of pre-existing or new medical problems.

Sources:

Bell J, Zador D. A risk-benefit analysis of methadone maintenance treatment. Drug Saf. 2000;22(3)179-190.

COMPA (New York State Committee of Methadone Program Administrators). Regarding Methadone Treatment and Other  Pharmacotherapies:   A Review. New York, NY: COMPA; revised 1999. See also: http:www.compa-ny.org

Humeniuk R, Ali R, White J, Hall W, Farrell M. Proceedings of Expert Workshop on the Induction and Stabilisation of Patients Onto Methadone. Monograph Series No. 39. Commonwealth Department of Health and Aged Care: Adelaide, South Australia; 2000.

Kreek, MJ. Health consequences associated with the use of methadone. In: Cooper JR, Altman F, Brown BS, Czechowicz D (eds). Research on the Treatment of Narcotic Addiction: State of the Art (NIDA Research Monograph 83-1201). Rockville, MD: National Institute on Drug Abuse; 1983.]

Kreek MJ. Medical safety and side effects of methadone tolerant individuals. JAMA. 1973;223(6):665-668.

Novick DM, Richman BL, Friedman JM, et al. The medical status of methadone maintenance patients in treatment for 11-18 years. Drug Alcohol Dep. 1993;33:235-245.

Rettig RA, Yarmolinsky A, eds. Institute of Medicine: Federal regulation of methadone treatment. Washington, DC: National Academy Press; 1995.

Torrens M. Methadone and quality of life. Lancet. 1999;353:1101.

Revised July 2009

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I’m On Methadone - Which Is Also A Painkiller - So What Happens If I Need Pain Medication?

When methadone was discovered in the late 1930s, it was found to be an effective agent to treat pain. So it is sometimes believed that people taking the drug daily as part of a methadone maintenance treatment program for addiction do not feel physical pain like everybody else.

This is untrue – patients stabilized on methadone feel pain just like anybody else would. And patients in methadone maintenance treatment who have pain have the same needs as other people for adequate pain medication.

For average pain that doesn’t last very long – such as a headache or muscle strain – over-the-counter painkillers (analgesics) should do the job. If pain is more severe or long-lasting, opioid painkillers with actions similar to morphine may be needed. Patients who are already used to an opioid drug (methadone) should talk to their doctor about the various drugs available for treatment. Additional medicines – like antidepressants or anti-seizure drugs – may be prescribed to help increase the effects of the analgesic.

Be aware that certain painkillers – such as Buprenex, Dalgan, Nubain, Stadol, Subutex, Suboxone, Talwin, and Ultram – can block the effects of methadone and could bring on uncomfortable withdrawal symptoms. Also, Darvon and Demerol are not recommended because harmfully high doses may be needed for effective pain relief in a patient maintained on methadone.

Patients definitely should inform the health care professionals treating their pain that they are on methadone maintenance. A professional who is unsure how best to treat the pain, or seems reluctant to prescribe stronger medication should contact the medical staff at the patient’s methadone clinic. Non-prescribed medications or street drugs (including alcohol) should never be taken along with pain medication.

 

For further information and references, see:

Pain perspectives - addiction, pain & MMT. Addiction Treatment Forum. 2004(Winter);13(1). Available at: http://www.atforum.com/SiteRoot/pages/current_pastissues/winter2004.shtml#anchor1

Methadone patients and the perils of pain. Addiction Treatment Forum. 1998(Spring);7(2). Available at: http://www.atforum.com/SiteRoot/pages/current_pastissues/spr98.shtml#anchor1222388

Revised July 2009

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Is Methadone Safe During Pregnancy?

A pregnant woman who abuses opioid drugs may seriously harm both herself and her unborn child. While methadone itself does not eliminate all potential problems of pregnancy, participation in medication-assisted treatment (MAT) greatly reduces the risks of illness or even death in mother or child.

Methadone is one of three medications approved in the U.S. for treating opioid addiction (the others are buprenorphine and naltrexone). Methadone is the only one recommended for use during pregnancy, and is considered the standard of care. It is not clear from published reports whether use of methadone in pregnancy has any lasting effect on the infant; many of the mothers in such studies use or abuse drugs in addition to their daily methadone.

A respected group of experts, gathered by the Institute of Medicine in 1995, concluded that methadone maintenance, combined with appropriate prenatal care, can reduce the incidence of complications in the mother or fetus. With proper methadone treatment, fetal growth is faster, resulting in higher birth weights, and illness or death in the newborn are less common. Withdrawal from methadone treatment is rarely appropriate during pregnancy, because relapse to illicit drug use is likely. Although a mild form of opioid withdrawal syndrome may occur in methadone-exposed infants, medical treatments are readily available to assist in appropriate care of the newborn child.

Methadone maintenance is considered vital for the health of pregnant opioid-addicted women. The federal regulations governing opioid treatment programs (OTPs) require that pregnant women be given a preference for admission and that arrangements be made for proper medical care during pregnancy. Years of experience and many careful studies have shown that there is no lasting harm to the child from exposure to methadone during pregnancy. And it is important to note that a baby born to a mother in MAT is always much better off both physically and mentally than if the woman had continued using heroin or other street drugs.

Pregnant patients in MAT can and do deliver healthy babies. Also, by no longer injecting drugs, these women avoid hazardous infections that could be transmitted to their infants. Moreover, participation in MAT allows the mothers to receive proper perinatal care, nutritional supplements, and parenting instructions.

It is true that the newborns sometimes experience withdrawal symptoms during the first several days after birth. However, the symptoms are routinely treated by pediatricians and do not result in any long-term damage. The neonates of women in MAT tend to have lower birth weights than those of drug-free women, but they do not exhibit any noteworthy developmental or neurological difficulties. Most important, compared with babies born to mothers on heroin, MAT has demonstrated great benefits to mothers and their infants.

Research has demonstrated that adequate methadone during pregnancy – at whatever dose is most effective for the mother – is not harmful to the fetus in terms of the incidence and severity of postnatal withdrawal syndrome. Research has indicated that dose increases may be required during later stages of pregnancy to maintain stability on methadone, and some clinicians recommend split doses for this purpose. At the same time, however, some of the older literature recommends that the dose during pregnancy not exceed 20 mg/day, and this potentially harmful myth still persists among some practitioners.

Sources:

Berghella V, Lim PJ, Hill MK, et al. Maternal methadone dose and neonatal withdrawal. Am J Obstet Gynecol. 2003;189:312-317.

Center for Substance Abuse Treatment (CSAT). Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs. Treatment Improvement Protocol (TIP) Series 43. DHHS Publication No. (SMA) 06-4214. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2005, reprinted 2006.

Farid WO, Dunlop SA, Tait RJ, Hulse GK.The Effects of Maternally Administered Methadone, Buprenorphine and Naltrexone on Offspring: Review of Human and Animal Data. Current Neuropharmacol. 2008;6(2):125-150.

Federal Regulation of Methadone Treatment. National Institute of Medicine. 1995. Available online at: http://www.nap.edu/books/0309052408/html/

Jones HE, Martin PR, Heil SH, et al. Treatment of opioid-dependent pregnant women: Clinical and research issues. J Subst Abuse Treat. 2008;35(3):245-59.

Revised July 2009

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heartIs Methadone Bad For The Heart?

Used appropriately as part of a medication-assisted treatment (MAT) program, methadone does not appear to cause heart problems directly, even at quite high doses.

There were some concerns during 2001 when LAAM (a long-acting cousin of methadone) was associated with disturbances of normal heartbeat, called cardiac arrhythmias. LAAM was taken off the market in Europe and manufacture of the product in the U.S. was discontinued.

To some extent, all opioids, including methadone, have an influence on heart function. Some of these effects are helpful. For example, people having heart attacks are sometimes given morphine. Other effects, which have been demonstrated mostly in animals or in test tube experiments, are not clearly helpful or harmful. However, methadone has generally not been found to be harmful to heart health in patients.

MAT patients may have heart problems just like anyone else. However, the health risks, heart-related and otherwise, for opioid-addicted individuals not in treatment are great, and death rates are high. MAT programs, of which methadone is a central part, provide a total health care environment potentially contributing to better heart health.

There also is some evidence that methadone maintenance preserves heart health. Having previously observed what might be a decreased amount of cardiovascular disease in MAT patients, a team of New York researchers investigated whether long-term exposure to opioid agents might be associated with decreased severity of coronary artery disease, believed to precede most heart attacks.

The investigators compared autopsy results in people who had methadone or opioids in their blood compared with the results in matched decedents (controls) without such drugs present. Severe coronary artery disease (CAD) was found significantly less often in decedents with methadone in their blood than in control-group decedents. In fact, subjects without methadone in their system were roughly 2½ times more likely to have moderate or severe CAD. Reasons for these possible cardioprotective effects of methadone were unclear, and require further research. However, the authors concluded that long-term exposure to methadone may lessen CAD severity and its often fatal consequences.

For more information and references, see:

Practitioner Panel – methadone and heart health. Addiction Treatment Forum. 2001(Summer);10(3). Available at: http://www.atforum.com/SiteRoot/pages/current_pastissues/summer2001.shtml#anchor1221360

Leavitt SB, Krantz M. Cardiac Conditions During MMT. Addiction Treatment Forum [White Paper Report]. October 2003. Available at: http://www.atforum.com/SiteRoot/pages/rxmethadone/cardiacmmt.shtml

Also: Marmor M, Penn A, Widmer K, Levin RI, Maslansky R. Coronary artery disease and opioid use. Am J Cardiol. 2004;93:1295-1297.

Revised July 2009

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medical testsShould Patients In MAT Have Special Heart-Health Tests?

Some patients in medication-assisted treatment (MAT) may have conditions or behaviors associated with increased risks of arrhythmia (irregular heart beat). These conditions include abuse of substances that damage the heart, cardiovascular disease, electrolyte imbalances, and prescribed medications that may affect the heart. Furthermore, data suggest that in some individuals, methadone – alone or, more commonly, in combination with other drugs or cardiac risk factors, or both – can influence the development of certain patterns of heart beat. These patterns (called long QT syndrome), may lead to a dangerous arrhythmia, called torsade de pointes, in a few susceptible patients.

It is important for healthcare practitioners to be aware of medical conditions and medications that might influence the development of arrhythmia during methadone maintenance. However, these should not be used to automatically exclude patients from entering or continuing MAT. Although some factors cannot easily or quickly be corrected, others might be modified or closely monitored during methadone maintenance.

Current evidence, however, does not support altering routine methadone dosing practices or requiring electrocardiograms (ECGs) for all patients entering or continuing MAT. The following general steps are recommended:

In sum, methadone remains an effective and well-tolerated therapy for the treatment of opioid addiction when prescribed appropriately. A sound understanding of its potential association with heart rhythm disturbances in the context of other heart disease factors will allow clinicians to optimize safety during methadone treatment.

Research in this area is ongoing and future refinements of these practices and implementation of new guidelines of treatment may be necessary.

For further information and references,

Leavitt SB, Krantz M. Cardiac Conditions During MMT. Addiction Treatment Forum [White Paper Report]. October 2003. Available at: http://www.atforum.com/SiteRoot/pages/rxmethadone/cardiacmmt.shtml

Revised July 2009

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Is Methadone Harmful For Medication-Assisted Treatment Patients With HIV/AIDS?hiv

Research with patients in medication-assisted treatment (MAT) shows that methadone does not make HIV infection or AIDS worse, nor does methadone interfere with treatment for these conditions. Studies in MAT patients have shown that methadone is not harmful, and may even help in recovery from HIV infection. In one investigation (see graph), MAT patients with HIV infection were compared with HIV-infected former injection-drug users (IDUs) not in treatment, and with individuals currently injecting illicit drugs. In the methadone-maintained patients the progression of HIV disease was one-third of that in the current IDUs, and also less than in the opioid-free former IDUs not in MAT. Importantly, over time, 10 persistent IDUs died of heroin overdoses, and 2 drug-free former IDUs relapsed and died. There were no such deaths in MAT patients.hiv progression

Although methadone does not appear to be damaging in people with HIV infection, or to interfere with anti-HIV treatment, two conclusions should be noted: 1. continued use of injected illicit drugs makes HIV infection worse; 2. MAT patients must receive adequate doses of methadone. In fact, one small study of MAT patients being treated for HIV infection found that their response to drug treatment was excellent; however, they needed about a 50% increase in methadone dose (on average), due to an interaction of certain anti-HIV medications with methadone.

For further information and references, see: Methadone & the immune system. Addiction Treatment Forum. 2002(spring);11(2). Available at: http://www.atforum.com/SiteRoot/pages/current_pastissues/spring2002.shtml#anchor1221360

Also, see: Leavitt SB. Methadone-Drug Interactions. Addiction Treatment Forum Updated November 2005. Available at: http://www.atforum.com/SiteRoot/pages/addiction_resources/Drug_Interactions.pdf

Updated July 2009

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Do I Have To Get Off Of Methadone To Be Treated For Hepatitis C?

Absolutely not. Unfortunately, patients in medication-assisted treatment (MAT) are sometimes told they must first withdraw from methadone or drastically reduce their dose to be treated for hepatitis or, if it’s needed, to receive a liver transplant operation.

There is no scientific evidence that methadone interferes in any way with treatment for hepatitis C (or for hepatitis B), or with liver transplantation. In fact, there have been clinical studies showing that MAT patients remaining on methadone do just as well as any other patients, if properly treated.

Also, U.S. Federal Guidelines on hepatitis C treatment, as well as those developed by other organizations, have supported the continued use of methadone in MAT patients during treatment for hepatitis. For example, a guideline released in 2004 from the American Society for the Study of Liver Diseases (AASLD) clearly states:

“The use of methadone or buprenorphine is an effective means of reducing illicit drug use and its complications. …there are several studies of persons taking methadone that suggest that the drug does not significantly reduce the likelihood of an SVR [sustained response to therapy], nor does it alter dosing of interferon or ribavirin. Therefore, methadone use does not directly affect the management of HCV infection.”

For further information and references, see:

Addiction Treatment Forum. Liver Disease in MMT: Treatment & Transplant – Parts 1-4. Available at: http://atforum.com/pdf/Liver_Dis_in_MMT.PDF

Strader DB, Wright T, Thomas DL, Seeff LB. Diagnosis, management, and treatment of hepatitis C. AASLD Practice Guideline. Hepatology. 2004;39(4):1147-1171. Available from AT Forum at: http://www.atforum.com/SiteRoot/pages/addiction_resources/AASLD_HCV_Guirader_et_al.pdf

NIDDK - Chronic Hepatitis C; Current Disease Management. Available at: http://atforum.com/SiteRoot/pages/addiction_resources/NIDDK_HC_Guide.PDF

NIH: Management of Hepatitis C: 2002. Available at: http://atforum.com/SiteRoot/pages/addiction_resources/NIH_HCV_Cons_2002Final.pdf

Revised July 2009

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Are Treatments For Hepatitis C Infection Effective In Patients Taking Methadone?

Up to 9 of every 10 injection drug users entering medication-assisted treatment (MAT) may be infected with hepatitis C virus (HCV), so this is an important question. It is especially critical, because MAT patients face many barriers to liver transplantation, which may be necessary for survival if HCV treatment is denied or ineffective.

This topic was discussed previously from an evidence-based perspective in a series of AT Forum articles during 2001 and 2002. The bottom-line answer is that treatments for HCV infection continue to improve, and MAT patients can respond as well as any other people.

About 170 million people world-wide are chronically infected with HCV. While signs of previous infection in the general population range between 0.2% and 2%, 50% to 90% of injection drug users are chronically infected with HCV. However, many patients who are in MAT are still excluded from treatment for HCV infection.

The authors of a review article examined clinical trials published between 1987 and 2003. The trials focused on the treatment of chronic infection with HCV in patients with drug addiction or in MAT. They found that patients who responded to anti-HCV treatment also responded as well to a methadone regimen as methadone patients in the general population. However, MAT patients with persistent drug abuse seemed more likely to discontinue treatment early.

A clinical trial reported in 2004 noted that the cure rate (no detectable virus after 6 months of anti-HCV treatment) in MAT patients was similar to that in the general population.

Sources:

1. Addiction Treatment Forum. Liver Disease in MMT: Treatment & Transplant – Parts 1-4. Available at: http://atforum.com/SiteRoot/pages/addiction_resources/Liver_Dis_in_MMT.PDF

2. Schaefer M, et al. Treatment of chronic hepatitis C in patients with drug dependence: time to change the rules? Addiction. 2004;99(9):1167-1175.

3. Mauss S, Berger F, Goelz J, Jacob B, Schmutz G. A prospective controlled study of interferon-based therapy of chronic hepatitis C in patients on methadone maintenance. Hepatology. 2004;40(1):120-124.

4. Torriani FJ, et al. Peginterferon alfa-2a plus ribavirin for chronic hepatitis C virus infection in HIV-infected patients. NEJM. 2004;351(5):438-450.

5. Chung RT, et al. Peginterferon alfa-2a plus ribavirin versus interferon alfa-2a plus ribavirin for chronic hepatitis C in HIV-coinfected persons. NEJM. 20o4;351(5):451-459.

Revised July 2009

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Why Does Methadone Make Me Put On Weight?

weight gain or lossThere is actually nothing about methadone or the way if affects the body that would make a person put on weight. However, this is a common complaint of patients in medication-assisted treatment (MAT) programs. A survey in 1984 reported that about 1 in 10 patients had gained weight, and 1 in 20 patients actually lost weight while on methadone. So, the situation is entirely opposite in different patients, which supports the view that methadone itself is not the cause.

One common explanation for the weight gain is water retention. In most cases, however, the patient is taking other medications that cause water retention, or there may be even other reasons. Many medications, such as some (but not all) antidepressants, cause weight gain.  Furthermore, many people in MAT are simply taking better care of themselves, and eating much better than they did while leading a life of substance addiction. A more healthful diet (talk to a dietitian) and some regular exercise could go a long way in helping to control weight problems.

Some people have believed that the prepackaged liquid form of methadone is fattening, which is untrue. For example, Methadose* cherry oral concentrate contains sugar to deter potential injection of the product. However, in a 100 milligram dose there are only about 15 calories – about the same as in one Life Saver candy, and about one-tenth as much as in a single can of a sweetened lemonade or cola drink.

This also means that the amount of sugar in this methadone product would not be harmful for people with diabetes. However, if there are still concerns, Methadose* brand of oral methadone concentrate comes in a sugarless formulation, which also is unflavored and colorless.

*Methadose® is a registered trade mark of Mallinckrodt, Inc.; St. Louis, MO.

Revised July 2009

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nutritionWhat Is The Role Of Diet And Nutrition In Addiction Recovery?

The American Dietetic Association (ADA) has officially recognized that, “Many debilitating nutritional consequences result from drug and alcohol abuse. Chronic nutrition impairment causes serious damage to the liver and brain, which reinforces the craving for more drugs and alcohol and perpetuates the psychological aspect of addiction.” Many people simply do not eat enough food or the right foods when they are preoccupied with seeking and taking drugs.

Furthermore, the ADA suggests, “Nutrition makes a difference in the rate and quality of physical recovery, which prepares individuals to function at a higher level in treatment – cognitively, mentally, and socially.”

Scientists seem to agree that substances of abuse may cause nutritional deficiencies; however, a direct link between nutritional deficiencies and addiction has not been fully accepted. Also, the notion that special diets or nutritional supplements or both may help treat addiction requires further research. But there are some obstacles and concerns to overcome:

Some specialists recommend that treatment professionals assess patients for malnutrition, and provide appropriate diet and nutrition education with the help of qualified nutritionists or dietitians, if indicated. However, relatively little is known in this area, based on sound clinical research, so appropriate caution is advised.

Source: Feeding recovery. Addiction Treatment Forum. 2004(Spring);13(2):1. Available at: http://www.atforum.com/SiteRoot/pages/current_pastissues/spring2004.shtml#anchor2

Revised July 2009

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Are Nutritional Supplements, Like Herbal Products, Safe To Use With Methadone?

nutritional supplementsSo-called “nutritional supplements” – including certain herbs, plants, and other “natural” substances (that is, found in nature) – have been used since ancient times to treat almost every human ailment. However, for several reasons, their use is not always safe or recommended.

For example, in June 2002 the government issued a warning about herbal products containing ephedra, also called ephedrine. The Ephedra species of herbs (also known by the Chinese name “ma huang”) was found in many products, such as those promoting weight loss, increased energy, or better sexual performance. However, in some people, the products can have powerful stimulant effects on the nervous system and heart that may cause serious harm. The interaction of ephedra-containing products with methadone is unpredictable.

Similarly, St. John’s wort, widely advertised to help overcome depression, can interact harmfully with prescribed antidepressant medications and other drugs. It may reduce methadone’s effects, and bring about withdrawal symptoms.

Therefore, at the least, anyone on medication-assisted treatment (MAT) should let clinic medical staff know what non-prescribed products they are using. It also is advisable to let staff know before taking any new supplement or drugstore product, even vitamins.

The government has formed an organization – the National Center for Complementary and Alternative Medicine – to more closely examine nutritional supplements and other treatments, such as acupuncture. For further information, their website is at http://www.nccam.nih.gov/

Revised July 2009

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