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The Lifetime Burden of Methadone, Buprenorphine Treatment

Posted on May 13, 2015 in Stimulants

Can you fight fire with fire? The use of methadone and buprenorphine to treat heroin addiction can be looked at as an attempt to do just that—giving opioid dependent individuals more opioids as “treatment” for their addiction. However, the reality of the situation is a little more nuanced, with evidence suggesting that the substitute drugs reduce risky behavior and keep individuals off heroin. Doctors around the country are now struggling with the question of whether this seemingly contradictory approach is the best strategy or whether they are simply allowing addiction to continue.   Methadone, Buprenorphine for Opioid Addiction  With the prescription drug epidemic wreaking havoc across the U.S. and increasingly driving users onto the cheaper and more accessible opioid that is heroin, any medicines with the potential to reduce overdose deaths and the burdens of addiction need to be considered. Methadone and buprenorphine accomplish this goal in basically the same way: providing a different source of opioids in a less risky package.   Although both drugs give users a hit of opioids, when taken as directed they don’t lead to euphoric effects, and both drugs have a relatively long “half-life” (the amount of time taken for half of the substance to leave the body) in comparison to heroin. This means that their addictive potential is reduced because the effects last longer and don’t lead to a spike in feel-good neurochemicals. By providing opioids in this way, the medicines reduce unpleasant withdrawal symptoms without producing euphoric effects. In addition, buprenorphine is often combined with naloxone (in the brand-name medication Suboxone)—a substance that blocks the effects of opioids—which becomes active if the medicine is crushed in an attempt to get a faster-acting hit.   Harm Reduction vs. Beating Addiction  The debate about using methadone and buprenorphine to treat heroin addiction ultimately comes down to the choice between reducing harm and beating addiction entirely. These medicines reduce harm because they mean that users don’t need to inject (which, when done with dirty needles, carries risks of conditions such as HIV), and users often replace heroin entirely with the medicines, thereby reducing the risk of overdose and death, as well as reducing criminal activity. According to the CDC, the death rate for opioid-dependent people on methadone maintenance therapy is 70 percent lower than for those not on the therapy. They also appear to reduce risky sexual behaviors and may be cost-effective, but the evidence on these points is conflicting or unreliable.    The big issue, though, is that you’re simply switching addiction from one type of opioid to another. It’s generally recommended that people be on methadone maintenance therapy for a year before attempting to wean themselves off the drug, for example, but in practice this can easily turn into several years. In addition, most patients either drop out, are encouraged to leave or are barred for failing to comply with program regulations within the first year, and the majority of these people relapse to heroin use. Other evidence suggests that most who end up trying to kick the medicines relapse within two years, and high numbers die from suicide or overdose.  Withdrawal may also be a factor even when taking the medicines, according to reports. A Minneapolis StarTribune reader who was addicted to pain meds talks of his burprenorphine-assisted withdrawal: “I was literally in the fetal position for the first week, and [had] the worst flu/hangover feeling for the next two weeks. Only after going back to the doctor for meds to help me withdraw from the Suboxone did I finally start to feel better.”   The Best Way to Get Clean Is Abstinence  There is a place for medicines like methadone and buprenorphine, but it’s a very confined one. They can reduce harm, but they also come with a big downside of continued addiction, so the drugs seem appropriate only when abstinence-based methods have proven to be unsuccessful, and even then the drug therapy should be combined with psychological support. If there is literally no other way to help someone, then allowing the addiction to continue in a less risky way is the most humane approach.   However, the key point is that the best way to get clean is by becoming abstinent. Yes, the withdrawal symptoms will be very unpleasant, but they will pass. Most importantly, abstinence-based approaches help people understand the underlying reasons they choose to use substances, promoting self-understanding and providing them with tools to overcome their triggers and cues to use drugs. In short, abstinence-based approaches treat addiction itself and reduce harm in the process, whereas methadone and buprenorphine reduce harm but allow addiction to continue.

Can you fight fire with fire? The use of methadone and buprenorphine to treat heroin addiction can be looked at as an attempt to do just that—giving opioid dependent individuals more opioids as “treatment” for their addiction. However, the reality of the situation is a little more nuanced, with evidence suggesting that the substitute drugs reduce risky behavior and keep individuals off heroin. Doctors around the country are now struggling with the question of whether this seemingly contradictory approach is the best strategy or whether they are simply allowing addiction to continue.

Methadone, Buprenorphine for Opioid Addiction

With the prescription drug epidemic wreaking havoc across the U.S. and increasingly driving users onto the cheaper and more accessible opioid that is heroin, any medicines with the potential to reduce overdose deaths and the burdens of addiction need to be considered. Methadone and buprenorphine accomplish this goal in basically the same way: providing a different source of opioids in a less risky package.

Although both drugs give users a hit of opioids, when taken as directed they don’t lead to euphoric effects, and both drugs have a relatively long “half-life” (the amount of time taken for half of the substance to leave the body) in comparison to heroin. This means that their addictive potential is reduced because the effects last longer and don’t lead to a spike in feel-good neurochemicals. By providing opioids in this way, the medicines reduce unpleasant withdrawal symptoms without producing euphoric effects. In addition, buprenorphine is often combined with naloxone (in the brand-name medication Suboxone)—a substance that blocks the effects of opioids—which becomes active if the medicine is crushed in an attempt to get a faster-acting hit.

Harm Reduction vs. Beating Addiction

The debate about using methadone and buprenorphine to treat heroin addiction ultimately comes down to the choice between reducing harm and beating addiction entirely. These medicines reduce harm because they mean that users don’t need to inject (which, when done with dirty needles, carries risks of conditions such as HIV), and users often replace heroin entirely with the medicines, thereby reducing the risk of overdose and death, as well as reducing criminal activity. According to the CDC, the death rate for opioid-dependent people on methadone maintenance therapy is 70 percent lower than for those not on the therapy. They also appear to reduce risky sexual behaviors and may be cost-effective, but the evidence on these points is conflicting or unreliable.

The big issue, though, is that you’re simply switching addiction from one type of opioid to another. It’s generally recommended that people be on methadone maintenance therapy for a year before attempting to wean themselves off the drug, for example, but in practice this can easily turn into several years. In addition, most patients either drop out, are encouraged to leave or are barred for failing to comply with program regulations within the first year, and the majority of these people relapse to heroin use. Other evidence suggests that most who end up trying to kick the medicines relapse within two years, and high numbers die from suicide or overdose.

Withdrawal may also be a factor even when taking the medicines, according to reports. A Minneapolis StarTribune reader who was addicted to pain meds talks of his burprenorphine-assisted withdrawal: “I was literally in the fetal position for the first week, and [had] the worst flu/hangover feeling for the next two weeks. Only after going back to the doctor for meds to help me withdraw from the Suboxone did I finally start to feel better.”

The Best Way to Get Clean Is Abstinence

There is a place for medicines like methadone and buprenorphine, but it’s a very confined one. They can reduce harm, but they also come with a big downside of continued addiction, so the drugs seem appropriate only when abstinence-based methods have proven to be unsuccessful, and even then the drug therapy should be combined with psychological support. If there is literally no other way to help someone, then allowing the addiction to continue in a less risky way is the most humane approach.

However, the key point is that the best way to get clean is by becoming abstinent. Yes, the withdrawal symptoms will be very unpleasant, but they will pass. Most importantly, abstinence-based approaches help people understand the underlying reasons they choose to use substances, promoting self-understanding and providing them with tools to overcome their triggers and cues to use drugs. In short, abstinence-based approaches treat addiction itself and reduce harm in the process, whereas methadone and buprenorphine reduce harm but allow addiction to continue.

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