Opiate Addiction and Mental Illness - Medication Assisted Treatment for the Treatment of an Opiate Use Disorder in the Co-occurring Population

Most of you reading this article will already have some familiarity with the realities associated with a co-occurring disorder of a substance use disorder in combination with an identified mental illness diagnosis.  We have finally put aside the “chicken or egg” argument of which came first or which should be prioritized in favor of treatment reflective of the depth of literature that suggests that if you have both diagnostic categories being met, treat them both and equally aggressively.  This article will look at the use of methadone for treating opiate addiction.

The opiate epidemic across much of the United States continues unabated. Due to the most recent oversight and restrictions being placed on the use of opiates for the management of pain, many individuals have taken steps to mitigate withdrawal symptoms with the use of heroin. For opiate abusers who have struggled with numerous attempts to quit, methadone may provide an alternative strategy for recovery.

Methadone is a synthetic agonist that works by "occupying" the brain receptor sites affected by heroin and other opiates. As such, it alleviates any current withdrawal symptoms as the individual dose is gradually raised to what is known as a ”blocking dose” , ostensibly blocking the brain’s receptors from opiates. It does not cause euphoria or intoxication itself (with stable dosing), thus allowing a person to work and participate normally in society. Once stabilized, an individual receiving methadone is indistinguishable from anyone else.

As the most researched addiction treatment methodology, the use of methadone has many benefits including:
•    Blocking the euphoric and sedating effects of opiates; 
•    Relieving the craving for opiates that is a major factor in relapse; 
•    Alleviates symptoms associated with withdrawal from opiates; 
•    It is metabolized slowly so it can be taken only once a day.

There are also numerous social benefits associated with the use of methadone:
•    Reduced or stopped use of injection drugs; 
•    Reduced risk of overdose and of acquiring or transmitting diseases such as HIV, hepatitis B or C, bacterial infections, endocarditis, soft tissue infections, thrombophlebitis, tuberculosis, and STDs; 
•    Reduced mortality - the median death rate of opiate-dependent individuals in methadone treatment  is 30 percent less than of the rate of those not receiving methadone;
•    Improved family stability; 
•    Employment potential; 
•    Improved pregnancy outcomes;
•    Reduced criminal activity.

In fact, for every $1 spent to maintain a patient on methadone there is a reduction in social costs of between $4 and $6, compared to an active substance abuser.

At this juncture, it’s also worth addressing the considerable amount of mythology associated with methadone maintenance, much of it predicated by continuing stigma of this treatment methodology. 

MYTH – Methadone simply replaces one addiction with another.
FACT - Taking methadone as prescribed is not an addiction. Patients will have physical dependency and will experience withdrawal if the medication is abruptly stopped (as is true of many medications). However, it does not cause impairment and allows an individual to regain a normal state of mind, free of drug-induced highs and lows.

MYTH – Methadone weakens the bones and rots your teeth.
FACT - Methadone does not "get into the bones" or in any other way cause harm to the skeletal system. Although some methadone patients report having aches in their arms and legs, the discomfort is probably a mild withdrawal symptom and may be eased by adjusting the patient’s dose of methadone. Also, some substances can cause more rapid metabolism of methadone. If a patient is taking another substance that is affecting the metabolism of methadone, the clinic doctor may need to adjust the patient’s methadone dose. Occasional dental problems are normal in human beings, even if they have never used drugs. When patients go on methadone maintenance therapy, they begin to abandon the “drug seeking” behavior that has dominated their lives in the past and to notice things they have ignored for a while, like the fact that they may need dental work.

MYTH - It's harder to kick methadone than it is to kick a dope habit.
FACT - Stopping methadone use is different from kicking a heroin habit. Some people find it harder because the withdrawal lasts longer. Others say that although the withdrawal lasts longer, it is milder than heroin withdrawal.

MYTH - Taking methadone damages your body.
FACT - People have been taking methadone for more than 40 years, and there has been no evidence that long-term use causes any physical damage whatsoever. Some people do have side effects from methadone such as constipation, increased sweating, and dry mouth, but these usually go away over time or with dose adjustments. Other effects, such as menstrual abnormalities and decreased sexual desire have been reported by some patients but have not been clearly linked to methadone use.

MYTH - Methadone causes drowsiness and sedation.
FACT - All people feel drowsy or tired at times. Patients on a stabilized dose of methadone will not feel any more drowsy or sedated than normal people feel during the day. When someone receiving methadone appears sedated, it is usually associated with the synergistic effects of other medications in combination with methadone, most often benzodiazepines. 

With all of these considerations in place, clinicians would serve psychiatric rehabilitation participants well by including the possibility of methadone maintenance with program participants who continue to struggle with an opiate use disorder.