methadone

As other noders have already noted, it's quite true that methadone is quite a bit more addictive than heroin. I've heard junkies say that "You can quit a smack habit, but methadone is forever." It's also true that methadone is at least as bad, if not worse, for you, than heroin, though the fact that methadone is administered in a clinical setting reduces many of these risks by quite a bit.

But the question remains: Why methadone maintenance therapy instead of heroin maintenance therapy? The reason is simple: methadone doesn't produce euphoria. The War on Drugs rhetoric, is I think responsible for this neo-Puritanism, the idea that anything that makes you happy must be a sin. More proof to my mind that the War on Drugs' basic impetus isn't reason or anything related, but just as fearful of pleasure as religion.

Methadone :- 6-dimethylamino-4,4-diphenyl-3-hep-tanone, C₂₁H₂₇NO

               (CH3)2N-CH-CH3     
             ___       |
            /   \      |
           /  _  \     |
          /  / \  \____C___CO___CH2CH3
          \  \_/  /    |
           \     /     |
            \___/      |___      
                       /   \
                      /  _  \
                     /  / \  \
                     \  \_/  /
                      \     /
                       \___/ 

Methadone is a white crystaline solid with a melting point of 232^oC, and has a bitter taste. It is considered useful in treating heroin addiction as it takes about a month before you get addicted to methadone. So you can perscribe it during the period the addict is suffering from withdrawal symptoms, without the patient becoming dependent on the methadone. Well that's the theory.....

Like methamphetamine before it, methadone was first explored and used widely by, guess who, the Nazis. In the very late thirties I.G. Farben was looking for non-addictive opioid anesthetics to replace the notoriously addictive morphine on the battlefield. At the time it wasn't known that any unnatural stimulation of the brain's opiate receptors would lead to their desensitization (and thus the person's addiction), so the research seemed perfectly reasonable. At some point during this period the I.G. discovered heroin, which, needless to say, had the opposite of the low addiction rate they were looking for. Other compounds were explored; unsurprisingly, none fitting the criterion were found.

In September of 1941, researchers Max Bockmuhl and Gustav Ehrart from the Hoescht branch of the corporation patented a chemical that they called Polamidon, which would eventually come to be known as methadone. One year later, the I.G. Farben proper sent the first sealed units to the German military for use and testing. Because the dosage ratios weren't well established, use of too much methadone at a time often led to nausea and overdose, so the drug never went into mass production or use.

At the end of the war, all of I.G. Farben's research and patent knowledge went to the United States, and the Eli-Lilly company ended up with control of methadone. They gave the drug the name Dolophine (from dolor, pain, and fin, the end) and began clinical trials. Again, nobody stopped to do proper dosage research, and the 200 mg, four times a day (!) dosages were far too much for most patients. They also noticed the rapid onset of tolerance, and the much lesser strength of euphoria than that caused by morphine. U.S. methadone manufacture was stopped for good in 1947, when a researcher named Isbell published work recommending that "unless the manufacture and use of methadone are controlled, addiction to it will become a serious health problem."

In the mid-to-late 1960's, drug clinics started becoming commonplace in the mainstream, and methadone maintenance treatment (MMT) was discovered for use in heroin addiction. With AMA support it caught on quickly becoming the standard treatment. Methadone lacked the euphoric rush of heroin, and its long half-life in the body meant withdrawals were kept away for more time. Also useful was the fact that methadone could be taken in tablet form, meaning that the patient wouldn't have to see needles or any other accouterments of heroin addiction.

Of course, as is noted above, that long lasting half-life of activation made methadone all the more addictive, and kicking it all the more difficult. Still, long-term maintenance prescriptions of methadone were much safer than heroin use on the street, so prescription and use were not limited by this addictivity. Many a heroin user went on to spend years addicted to methadone, due to a combination of overworked, overprescriptive drug clinics and the chemical's difficulty to stop using.

This pattern continued, and escalated heavily in the 1980's with the rise of HIV AIDS. Sadly, heroin use had been skyrocketing through the early 80's, and for much of that time the transmission route and danger of AIDS was widely unknown. These factors combined to make injecting heroin an order of magnitude more dangerous than it had been in the 60's and 70's, and even greater usage of methadone maintenance prescriptions. Because of the attention paid to HIV, enough money was gradually funneled to MMT clinics that they could afford continuous daily monitoring and regulation of their patients. As of 1992 the United States had over 120,000 of these patients in 800 programs receiving daily methadone maintenance.

Contrary to popular belief, methadone DOES produce euphoria same as any other opiate. However, methadone provides no rush, unlike heroin, morphine, or other commonly injected opiates, because it must be metabolized in your liver first to produce the desired high.* Even if it is intravenously injected, methadone will typically take up to 1-2 hours to take full effect. This just means that methadone has a longer onset than heroin, but it can still provide just as intense a euphoria as diamorphine, otherwise, it would not be used to treat heroin addiction. And it remains debatable whether methadone clinics actually help drug addicts kick addiction. You can replace one opiate addiction with another, but can you use an opiate to cure an opiate addiction?

Here are some facts:

• Methadone is about 1.5 times as potent as morphine, oxycodone, and heroin by mass.
• Methadone has a much longer half-life than heroin, thus stays in your body much longer.
• Methadone is much more expensive than heroin.

So does it really make sense to treat one addiction by replacing it with another addiction to a stronger opiate, that takes longer to detox from, that is also much more expensive? YES, it does, because then you are supporting pharmaceutical companies that can make a "legitimate" profit off of your addiction.

My point is not that methadone clinics are completely useless, or that methadone maintenance has not helped anyone live a healthier life. It is true that some people have used methadone to kick their heroin habit, and any kind of drug administered in a clinical environment will definitely be much safer than using street drugs elsewhere. But for the most part, methadone clinics just substitute one addiction for a much worse and expensive one. Their main purpose seems to be turning a societal problem into a source of revenue. Methadone maintenance really just legitimizes corporate narcotics trafficking because illicit or not, methadone is still just another narcotic.

Many people are skeptical about methadone maintenance programs, and for good reason. Here is an excerpt from the CPSO's Methadone Maintenance Guidelines:

Methadone maintenance typically involves the daily oral administration of methadone over an extended period of time as a substitute for heroin or other short acting opioids to opioid dependent individuals. Once an individual has been stabilized on a dose of methadone, subsequent daily doses should not cause sedation, analgesia or euphoria. Methadone is long acting; it can prevent the occurrence of withdrawal symptoms or cravings when a patient receives an optimal dose. This enables individuals to function normally and to perform mental and physical tasks without impairment. In sufficient doses, cross-tolerance to other opioids develops i.e. methadone “blocks” the euphoric effects of self-administered illicit opioids.
Numerous studies have shown that maintaining opioid dependent individuals on methadone has many benefits including: (1) reduced illicit drug use, (2) improved health status as a result of access to treatment, (3) decreased transmission of HIV and HCV, HBV, (4) decreased illegal activity, (5) increased employment (6) decreased cost to society and (7) decreased mortality. Further, one of the indirect benefits of methadone treatment is that patients come into contact with other services – counseling, vocational services, and needle exchange programs.

But consider the following points:

• Methadone management rarely cures opioid dependency. Thus, most patients to MM programs have to receive "treatment" for the rest of their lives or simply drop out of the program and continue "illicit" drug use.
• Unless administered with naloxone or another opioid antagonist, methadone still causes sedation, analgesia, and euphoria. So other than the clinical setting of drug administration, methadone is really no different from any other opiate as far as its addiction potential.
• Methadone only prevents withdrawal symptoms and cravings as long as the patient is still using. This is true with heroin also. Except heroin withdrawal doesn't last as long.
• Developing cross-tolerance to other opioids is simply increasing your body's dependency and tolerance for opioids in general. This touted advantage of methadone maintenance is akin to getting an addict accustomed to such high doses of heroin that regular doses and routes of administration no longer suffice. This essentially assures that methadone maintenance patients have to keep coming back for more methadone, or start using more potent opiates such as sufentanyl, or china white.
• It might be true that MM reduces "illicit" drug use, but this only serves to put a new label on the patient's addiction. So now the patient is using a drug that is much worse for them physically and is also more expensive, but since the drug is supplied to users legally the situation is assumed to have improved.
• MM does decreases the transmission of HIV, HBV, and HCV, but this can also be accomplished by funding more needle exchange programs which would give these health benefits to all users, rather than limiting benefits to just those who can afford to enter MM. This advantage also exists with heroin maintenance programs, which make a lot more sense in my opinion.

In short, methadone provides no advantages as a substitute for heroin except that methadone is legally marketed to users, and being addicted to methadone doesn't carry the same social stimga as being addicted to heroin does. Methadone allows those who can afford it to maintain a job, and a normal life by freeing them from legal persecution by putting a legitimate label on their drug habit. The distinction between licit and illicit drugs is quite arbitrary so decreasing the usage of illicit drugs while increasing the usage of licit drugs which feed the same problem makes very little progress if any.

EDIT:

People need to understand that methadone maintenance is not meant to get addicts to eventually achieve full abstinence. Going on MM thinking this would be a huge mistake. The purpose of MM is to allow individuals suffering from opioid dependency to still live a "normal life." From the beginning researchers have known that once a patient stops MM that they are pretty much guaranteed to have a relapse.

The way methadone maintenance came about was that Dr. Vincent P. Dolem, one of the primary proponents of methadone maintenance treatment theory, observed that if addicts were given methadone indefinitely, rather than being tapered off and forced to detox, they could "become normal, well-adjusted, effectively functioning human beings"--as long as they continued to take their daily dose of methadone. Dr. Dole also observed that when patients left the program and experienced a relapse, they craved heroin, not methadone. From these observations it was concluded that methadone was less addictive than heroin and does not cause cravings, and that methadone maintenance, "to all intents and purposes cured of their craving for an illegal drug."

Now there are several key mistakes that I see in the premises of Dr. Dole's argument for methadone maintenance:

Dr. Dole concluded that because patients craved heroin isntead of methadone when they left the program, this made methadone a safer drug, and also one better suited for maintenance treatment. The problem with this is that:

• It isn't true that methadone is any less addictive than heroin. Methadone is much more potent than heroin, so it can get you just as high as heroin, if not higher. The problem is, when you are not on MM, methadone is damn near impossible to get.
• In 2002, methadone killed 103 people in Oregon. That is 2 more fatalities than heroin, making methadone the state's most lethal drug. This occured when the Oregon Health Plan began prescribing methadone as a pain-killer and the drug became widely available for abuse.
• Because methadone has a much longer half-life than heroin, such that it lingers in the body even after the euphoria has faded, it is easier to overdose on methadone than it is on heroin.

Methadone maintenance programs are also based on the assumption that patients using heroin cannot function normally in society but patients using methadone can still lead relatively functional lives. This is patently untrue. The physical and psychological effects of methadone use are nearly identical to that of heroin use other than the duration and onset of the high. If legally supplied and administered in a clinical setting, a heroin habit can be maintained in much the same way as methadone. Much of the problem lies in the media's portrayal of heroin and heroin users. Heroin is portrayed as such a detrimental and immediately addicting drug that it is almost necessary for a substitute to be used in place of heroin for any sort of treatment. People refuse to believe that there are healthy, productive members of society out there who secretly use heroin unbeknownst to those around them.
Heroin users can be dependant on the drug, thus be addicted to it, without abusing it. Because most of the negative effects of heroin use is related to the War on Drugs and the illegal status of the heroin, chronic responsible use poses no serious health risks. However, this idea contradicts everything the government has said about heroin so ofcourse heroin maintenance will never be a viable option in the U.S.

* - Before methadone can produce desired effects it has to first be metabolized in your liver to a product your body can use. Excess methadone is also stored in the liver as well as in the blood stream. This acts as a sort of biological time-release mechanism and accounts for methadone's relatively long duration of action.

Sources:
Brecher, Edward M. The Consumers Union Report on Licit and Illicit Drugs: Chapter 14. Enter methadone maintenance. 16 Sept. 2004 <http://www.druglibrary.org/schaffer/Library/studies/cu/CU14.html>
Frequently Asked Questions. Methadone Today. 16 Sept. 2004 <http://www.methadonetoday.org/faq.htm>