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(New page: {{ClinPsy}} '''Methadone maintenance''' is the use of methadone over a prolonged time as treatment for someone who is addicted to heroin or has severe pain proble...)
 
 
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{{ClinPsy}}
 
{{ClinPsy}}
'''Methadone maintenance''' is the use of [[methadone]] over a prolonged time as treatment for someone who is [[addiction|addicted]] to [[heroin]] or has severe [[pain]] problems that are resistant to other drugs.
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'''Methadone maintenance'''(MMT) is a form of [[maintenance therapy]] in which the use of [[methadone]] over a prolonged time is used as a treatment for someone who has a [[heroin addction]] or has severe [[pain]] problems that are resistant to other drugs.
   
==Modality==
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Methadone Maintenance Treatment (MMT) reduces and/or eliminates the use of heroin, and criminality associated with heroin use, and allows patients to improve their health and social productivity<ref name="JosephStancliffLangrod"/>. In addition, enrollment in methadone maintenance has the potential to reduce the transmission of infectious diseases associated with heroin injection, such as hepatitis and HIV.<ref name="JosephStancliffLangrod"/> The principal effects of methadone maintenance are to relieve narcotic craving, suppress the abstinence syndrome, and block the euphoric effects associated with heroin. Methadone maintenance has been found to be medically safe and [[non-sedating]].<ref name="JosephStancliffLangrod"/> It is also indicated for pregnant women addicted to heroin.<ref name="JosephStancliffLangrod"> {{cite journal |author=Joseph H, Stancliff S, Langrod J |title=Methadone maintenance treatment (MMT): a review of historical and clinical issues |journal=Mt. Sinai J. Med. |volume=67 |issue=5-6 |pages=347–64 |year=2000 |pmid=11064485 |doi=}}</ref>
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In Russia, methadone treatment is illegal. Health officials are not convinced of the treatment's efficacy. Instead, doctors encourage immediate abstinence from drug use, rather than the gradual process that methadone substitution therapy entails. Patients are often given sedatives and painkillers to cope with withdrawal symptoms<ref>M Schwirtz. "Russia Scorns Methadone for Heroin Addiction." The New York Times. July 22, 2008.</ref>.
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===Effect===
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Methadone maintenance treatment significantly decreases the rate of [[HIV]] infection for those patients participating in MMT programs (Firshein, 1998). At proper dosing, methadone usually reduces the appetite for and need to take heroin. Furthermore doses ≥40mg and above provide cross-tolerance and block the euphoric effects of other opioids such as [[heroin]], [[fentanyl]], [[hydrocodone]], [[oxycodone]], [[hydromorphone]], and [[morphine]] or [[codeine]] syrup, thus greatly reducing the motivation of patients to use them.
  +
  +
Methadone offers patients the freedom from active addiction and use of mind-altering drug use and in turn allows them to seek concurrent psychological, psychiatric and self-help based therapies for both the disease of addiction and any comorbid illnesses they have, freedom they would not have when experiencing severe ongoing withdrawal and/or cravings. In addition, and perhaps most importantly, methadone allows addicts to become productive members of society; freed from the need to obtain money through often illicit means, opiate addicts can return to their normal lives, or develop skills, further their education, and (re)join the workforce.
  +
  +
A proper dose used in methadone maintenance therapy will block or greatly reduce cravings and illicit opioid use while not inducing any euphoric feelings or other subjective sense of being high, and if high enough will actively prevent the patient from experiencing any high if they do use other opioids.
  +
Methadone-based treatment is significantly more effective clinically and more cost effective than no-drug treatment modalities for opiate-dependent patients.<ref name="Connock">{{cite journal |author=Connock M, Juarez-Garcia A, Jowett S, ''et al'' |title=Methadone and buprenorphine for the management of opioid dependence: a systematic review and economic evaluation |journal=Health technology assessment (Winchester, England) |volume=11 |issue=9 |pages=1–171, iii–iv |year=2007 |pmid=17313907 |doi=}}</ref>
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===Dosage===
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A majority of patients require 80-120 mg/d of methadone, or more, to achieve these effects and require treatment for an indefinite period of time, since methadone maintenance is a corrective but not a curative treatment for opiate addiction.<ref name="JosephStancliffLangrod"/> Lower doses are sometimes not as effective or provide the blockade effect as higher dosages. Some patients will be prescribed as much as 500mg of methadone a day, though a person without a methadone tolerance may get sick from a dose as low as 20mg.
  +
  +
In the United States clinics typically start patients at a low dose, generally only starting patients on methadone when they are in withdrawal and providing a small test dose, after which the patients are observed for possible adverse effects. Assuming there are no complications, the remaining portion of the first day's dose is then given. After this the doses are titrated until they reach either a clinically sufficient level that prevents withdrawal, cravings and possible continued use of illicit opioids, or until they reach a maximum dose set by clinic policy. For example, a clinic may start patients at 30mg and raise the dosage 5mg a day until the addict feels they are at a comfortable level of dosage or will stop at 80mg and allowing the patient move up by 5mg or 10mg every 2 or 3 days, free from withdrawal symptoms and intense cravings. Once stabilized patients may require occasional dose adjustments as their clinical or subjective tolerance changes.
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  +
The most common and traditional dosing regimens, however, tend to fall far short of providing optimum or even sufficient results for a number of patients. This is due to the ceilings many clinics place on dose levels.<ref name="DonnyBrasser">{{cite journal |author=Donny EC, Brasser SM, Bigelow GE, Stitzer ML, Walsh SL |title=Methadone doses of 100 mg or greater are more effective than lower doses at suppressing heroin self-administration in opioid-dependent volunteers |journal=[[Addiction (journal)|Addiction]] |volume=100 |issue=10 |pages=1496–509 |year=2005 |pmid=16185211 |doi=10.1111/j.1360-0443.2005.01232.x}}</ref><ref name="pmid17373567">{{cite journal |author=Latowsky M |title=Methadone death, dosage and torsade de pointes: risk-benefit policy implications |journal=Journal of psychoactive drugs |volume=38 |issue=4 |pages=513–9 |year=2006 |pmid=17373567 |doi=}}</ref>
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A 100-mg dose has become accepted as a 'glass ceiling', rarely to be penetrated, and in practice much lower thresholds are maintained even though the optimal dose varies greatly between patients, often quite higher than this and with no inherent threshold in the possible dose, as the toxic dose for patients with very high tolerance can exceed this ten-fold or more. The blood concentrations of patients on an equivalent dose, when adjusted for body weight, can vary as much as 17-fold, or up to 41-fold when influenced by other medications, leading to a vast range of potentially required doses.<ref name=Eap>{{cite journal |author=Leavitt SB, Shinderman M, Maxwell S, Eap CB, Paris P |title=When "Enough" Is Not Enough: New Perspectives on Optimal Methadone Maintenance Dose|journal= Mount Sinai Journal of Medicine |volume=67 |issue=5&6 |pages=404–411 |year=2000}}</ref><ref name="Faggiano">{{cite journal |author=Faggiano F, Vigna-Taglianti F, Versino E, Lemma P |title=Methadone maintenance at different dosages for opioid dependence |journal=Cochrane database of systematic reviews (Online) |volume= |issue=3 |pages=CD002208 |year=2003 |pmid=12917925 |doi=10.1002/14651858.CD002208}}</ref>
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===Duration===
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While there is much debate over the treatment schedule and duration required, treatment at a methadone maintenance clinic is intended to be for an indefinite duration, lasting as long as the patient requires it. Many factors determine the treatment dose schedule. In general, methadone maintenance is seen as ongoing symptom management rather than a curative treatment. Compared to other narcotics (morphine, hydrocodone, heroin), methadone is much safer (when used as directed) and does not harm any of the body's vital organs (brain, liver, lungs, kidneys) even after long term use (30+ years).
  +
  +
===Visits to clinics===
  +
Methadone has traditionally been provided to people who are opiate dependent in a highly regulated [[methadone clinic]], generally associated with an [[outpatient]] department of a hospital, though this varies country by country. For example in Australia, Methadone maintenance treatment (MMT) is delivered by private pharmacies for a nominal fee to the client (regardless of the fact it is free as it is subsidised by the Federal government).
  +
  +
In many Western countries, new patients are required to visit the clinic daily so that they may be observed taking their dose by the dispensing nurse, but may be allowed to leave the clinic with increasing supplies of "take home doses" or "carries" after several months of adherence to the clinic's regulations, including consistent negative drug-screen results. The way that MMT is delivered in some countries create barriers to scaling up access to the treatment. For example, in Australia, people who are on MMT are dosed in a designated area in front of other pharmacy customers. This can inhibit people's willingness to access treatment due to a lack of confidentiality and anonymity. In some countries or regions, law stipulates that clinics may provide at most one week's worth of methadone, (up to 30 days in the USA) except for patients unable to visit the clinic without undue hardship due to a medical disability or infrequent exceptions made for necessary travel to areas without clinics, and this level is only reached after a few years of proper results.
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  +
Some people treated for MMT at a specific MMT clinic receive psychological counseling, which is also provided on site. Though the laws vary, this is required by law in many states and countries. In some countries psycho-social support, including counseling, is compulsory, regardless of whether a person needs or wants to engage in that kind of intervention (for example, recent changes in Taiwan).
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<!--Additional text that may be of use
 
Methadone has been used to treat opioid dependence for thirty-five years. Therapeutic dosing is contingent upon individual patient needs, and the therapeutic dosage range is generally between 80 - 120 mg. Though it should be noted that such a dose would likely not be tolerated by an opioid naive individual. Methadone is taken orally and is rapidly absorbed from the gastrointestinal tract, appearing in plasma within thirty minutes of being ingested. Methadone is also widely distributed to body tissues where it is stored and then released into the plasma. This combination of storage and release keeps the patient comfortable, free from craving, and feeling stable.
 
Methadone has been used to treat opioid dependence for thirty-five years. Therapeutic dosing is contingent upon individual patient needs, and the therapeutic dosage range is generally between 80 - 120 mg. Though it should be noted that such a dose would likely not be tolerated by an opioid naive individual. Methadone is taken orally and is rapidly absorbed from the gastrointestinal tract, appearing in plasma within thirty minutes of being ingested. Methadone is also widely distributed to body tissues where it is stored and then released into the plasma. This combination of storage and release keeps the patient comfortable, free from craving, and feeling stable.
   
With the emergence of several treatment options such as [[buprenorphine]] and heroin treatment (Switzerland & U.K.) since 1990 many professionals no longer hold with the opinion of the General Accounting Office and maintain that buprenorphine or detoxification are superior.
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With the emergence of several treatment options such as [[buprenorphine]] and heroin treatment (Switzerland & U.K.) since 1990 many professionals no longer hold with the opinion of the General Accounting Office and maintain that buprenorphine or detoxification are superior. -->
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==See also==
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*[[Drug addiction]]
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*[[Drug rehabilitation]]
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==References==
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{{reflist}}
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==External links==
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* [http://www.whitehousedrugpolicy.gov/publications/factsht/methadone/index.html ONDCP Fact Sheet]
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* [http://dpt2.samhsa.gov/treatment/ Clinic Locator, United States]
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* [http://www.cdc.gov/IDU/facts/MethadoneFin.pdf DHHS, Centers for Disease Control and Prevention (CDC)]
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* [http://www.methadone.org Methadone.org]
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* [http://www.MethadoneSupport.org Methadone Support]
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* [http://www.HARMD.org HARMD Inc. Helping America Reduce Methadone Deaths]
   
 
[[Category:Addiction]]
 
[[Category:Addiction]]
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{{enWP|Methadone}}

Latest revision as of 17:09, November 28, 2008

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Methadone maintenance(MMT) is a form of maintenance therapy in which the use of methadone over a prolonged time is used as a treatment for someone who has a heroin addction or has severe pain problems that are resistant to other drugs.

Methadone Maintenance Treatment (MMT) reduces and/or eliminates the use of heroin, and criminality associated with heroin use, and allows patients to improve their health and social productivity[1]. In addition, enrollment in methadone maintenance has the potential to reduce the transmission of infectious diseases associated with heroin injection, such as hepatitis and HIV.[1] The principal effects of methadone maintenance are to relieve narcotic craving, suppress the abstinence syndrome, and block the euphoric effects associated with heroin. Methadone maintenance has been found to be medically safe and non-sedating.[1] It is also indicated for pregnant women addicted to heroin.[1]

In Russia, methadone treatment is illegal. Health officials are not convinced of the treatment's efficacy. Instead, doctors encourage immediate abstinence from drug use, rather than the gradual process that methadone substitution therapy entails. Patients are often given sedatives and painkillers to cope with withdrawal symptoms[2].

EffectEdit

Methadone maintenance treatment significantly decreases the rate of HIV infection for those patients participating in MMT programs (Firshein, 1998). At proper dosing, methadone usually reduces the appetite for and need to take heroin. Furthermore doses ≥40mg and above provide cross-tolerance and block the euphoric effects of other opioids such as heroin, fentanyl, hydrocodone, oxycodone, hydromorphone, and morphine or codeine syrup, thus greatly reducing the motivation of patients to use them.

Methadone offers patients the freedom from active addiction and use of mind-altering drug use and in turn allows them to seek concurrent psychological, psychiatric and self-help based therapies for both the disease of addiction and any comorbid illnesses they have, freedom they would not have when experiencing severe ongoing withdrawal and/or cravings. In addition, and perhaps most importantly, methadone allows addicts to become productive members of society; freed from the need to obtain money through often illicit means, opiate addicts can return to their normal lives, or develop skills, further their education, and (re)join the workforce.

A proper dose used in methadone maintenance therapy will block or greatly reduce cravings and illicit opioid use while not inducing any euphoric feelings or other subjective sense of being high, and if high enough will actively prevent the patient from experiencing any high if they do use other opioids. Methadone-based treatment is significantly more effective clinically and more cost effective than no-drug treatment modalities for opiate-dependent patients.[3]

DosageEdit

A majority of patients require 80-120 mg/d of methadone, or more, to achieve these effects and require treatment for an indefinite period of time, since methadone maintenance is a corrective but not a curative treatment for opiate addiction.[1] Lower doses are sometimes not as effective or provide the blockade effect as higher dosages. Some patients will be prescribed as much as 500mg of methadone a day, though a person without a methadone tolerance may get sick from a dose as low as 20mg.

In the United States clinics typically start patients at a low dose, generally only starting patients on methadone when they are in withdrawal and providing a small test dose, after which the patients are observed for possible adverse effects. Assuming there are no complications, the remaining portion of the first day's dose is then given. After this the doses are titrated until they reach either a clinically sufficient level that prevents withdrawal, cravings and possible continued use of illicit opioids, or until they reach a maximum dose set by clinic policy. For example, a clinic may start patients at 30mg and raise the dosage 5mg a day until the addict feels they are at a comfortable level of dosage or will stop at 80mg and allowing the patient move up by 5mg or 10mg every 2 or 3 days, free from withdrawal symptoms and intense cravings. Once stabilized patients may require occasional dose adjustments as their clinical or subjective tolerance changes.

The most common and traditional dosing regimens, however, tend to fall far short of providing optimum or even sufficient results for a number of patients. This is due to the ceilings many clinics place on dose levels.[4][5]

A 100-mg dose has become accepted as a 'glass ceiling', rarely to be penetrated, and in practice much lower thresholds are maintained even though the optimal dose varies greatly between patients, often quite higher than this and with no inherent threshold in the possible dose, as the toxic dose for patients with very high tolerance can exceed this ten-fold or more. The blood concentrations of patients on an equivalent dose, when adjusted for body weight, can vary as much as 17-fold, or up to 41-fold when influenced by other medications, leading to a vast range of potentially required doses.[6][7]

DurationEdit

While there is much debate over the treatment schedule and duration required, treatment at a methadone maintenance clinic is intended to be for an indefinite duration, lasting as long as the patient requires it. Many factors determine the treatment dose schedule. In general, methadone maintenance is seen as ongoing symptom management rather than a curative treatment. Compared to other narcotics (morphine, hydrocodone, heroin), methadone is much safer (when used as directed) and does not harm any of the body's vital organs (brain, liver, lungs, kidneys) even after long term use (30+ years).

Visits to clinicsEdit

Methadone has traditionally been provided to people who are opiate dependent in a highly regulated methadone clinic, generally associated with an outpatient department of a hospital, though this varies country by country. For example in Australia, Methadone maintenance treatment (MMT) is delivered by private pharmacies for a nominal fee to the client (regardless of the fact it is free as it is subsidised by the Federal government).

In many Western countries, new patients are required to visit the clinic daily so that they may be observed taking their dose by the dispensing nurse, but may be allowed to leave the clinic with increasing supplies of "take home doses" or "carries" after several months of adherence to the clinic's regulations, including consistent negative drug-screen results. The way that MMT is delivered in some countries create barriers to scaling up access to the treatment. For example, in Australia, people who are on MMT are dosed in a designated area in front of other pharmacy customers. This can inhibit people's willingness to access treatment due to a lack of confidentiality and anonymity. In some countries or regions, law stipulates that clinics may provide at most one week's worth of methadone, (up to 30 days in the USA) except for patients unable to visit the clinic without undue hardship due to a medical disability or infrequent exceptions made for necessary travel to areas without clinics, and this level is only reached after a few years of proper results.

Some people treated for MMT at a specific MMT clinic receive psychological counseling, which is also provided on site. Though the laws vary, this is required by law in many states and countries. In some countries psycho-social support, including counseling, is compulsory, regardless of whether a person needs or wants to engage in that kind of intervention (for example, recent changes in Taiwan).


See alsoEdit

ReferencesEdit

  1. 1.0 1.1 1.2 1.3 1.4 Joseph H, Stancliff S, Langrod J (2000). Methadone maintenance treatment (MMT): a review of historical and clinical issues. Mt. Sinai J. Med. 67 (5-6): 347–64.
  2. M Schwirtz. "Russia Scorns Methadone for Heroin Addiction." The New York Times. July 22, 2008.
  3. Connock M, Juarez-Garcia A, Jowett S, et al (2007). Methadone and buprenorphine for the management of opioid dependence: a systematic review and economic evaluation. Health technology assessment (Winchester, England) 11 (9): 1–171, iii–iv.
  4. Donny EC, Brasser SM, Bigelow GE, Stitzer ML, Walsh SL (2005). Methadone doses of 100 mg or greater are more effective than lower doses at suppressing heroin self-administration in opioid-dependent volunteers. Addiction 100 (10): 1496–509.
  5. Latowsky M (2006). Methadone death, dosage and torsade de pointes: risk-benefit policy implications. Journal of psychoactive drugs 38 (4): 513–9.
  6. Leavitt SB, Shinderman M, Maxwell S, Eap CB, Paris P (2000). When "Enough" Is Not Enough: New Perspectives on Optimal Methadone Maintenance Dose. Mount Sinai Journal of Medicine 67 (5&6): 404–411.
  7. Faggiano F, Vigna-Taglianti F, Versino E, Lemma P (2003). Methadone maintenance at different dosages for opioid dependence. Cochrane database of systematic reviews (Online) (3): CD002208.

External linksEdit

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