OPIOID MAINTENANCE

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One of the most common misconceptions held about opiod maintenance is that its primary function is to help a person stop using drugs.  While this is certainly a laudable goal, it should not be the primary focus.  The primary goal should be to return the client to a normal, productive lifestyle with gainful employment and good relationships and the absence of psychiatric disease. 

It may be that this can be accomplished via stabilization and weaning of with a medication like Suboxone.  Since weaning will be less intrusive to the patient in the long run, it should be considered and attempted in almost all cases.  However, if these attempts fail, there is nothing wrong with long-term (perhaps even lifetime) maintenance with Suboxone or Methadone.

Suboxone and Methadone are different from most abused drugs.  Most abused opiates are short acting drugs. This means they get into the body quickly and are metabolized quickly.  When the drug is taken, there is a quick upsurge in the concentration of the drug in the brain.  This results in euphoria and intoxication.   When tolerance develops, there are problems relating to the wearing off of the medication that occurs hours after the last dose.  It leads to a mild degree of withdrawal and will adversely affect concentration, mood, and neurological function.  The body will be under stress leading to a cascade of abnormal hormonal functions and immune suppression.  The patient will obsess over drugs and resort to all sorts of aberrant behavior in order to obtain them.  These behaviors not only disrupt the life of the addict and those around him, but affect us all through crime, motor vehicle accidents, other trauma, higher health costs and the need to maintain a variety of governmental interventions. 

Traditionally, treatments based on achieving abstinence have had high failure rates even when there has been multiple, prolonged treatments.   Current medical theory suggests prolong physiological aberrations in the body’s normal opiate and emotional systems.  “JUST SAY NO” does not work in the face of such obstacles and many patients are unable to remain drug free.

When methadone or Suboxone is used, there is no upsurge of the drug in the brain. Therefore, there is no euphoria or intoxication and the body can become healthier.  There is also no withdrawal later in the day.  Many patients can and do lead more productive lives.

Those patients who continue to abuse drugs may still be in a better functional state with maintenance than they would have been without maintenance.  Methadone and buprenorphine maintenance are designed to treat opiate dependency.  They do not treat psychological dysfunction.  They do not help other types of drug dependencies such as cocaine, sedative or alcohol. 

The continued abuse of other drugs does not mean that treatment has failed.  The patient may still appear out of control and is tempting to blame the methadone for the problem.  However, Methadone and Buprenorphine are still usually part of the solution and not part of the problem.  If the maintenance drug is withdrawn, the situation will get worse.

Methadone’s usefulness in maintenance was recognized 40 years ago.  Initially, it was widely prescribed without restriction.  Alas, if you put a lot of opiate into the community it will be abused.  Methadone and Buprenex are also addictive, albeit, to a lesser degree.  Addiction, diversion and overdose became problems when methadone use began.  In order to combat these problems, clinics were developed to minimize the amount of drug on the street as well to engage the addict in a full range of services including closer monitoring and counseling.  Unfortunately, there are lots of regulations.  This makes being on methadone very cumbersome and patients, especially working patients, do not have adequate access to treatment. 

Yet Methadone has been the most successful treatment to date in minimizing illegal behaviors, optimizing pregnancy outcomes, preventing HIV infection and restoring people to functionality.  It is inexpensive (not counting the cost of a clinic), effective and able to stabilize opiod dependent patients even with very high tolerances.

It does not get into the bones or cause serious medical problems.  It has other physiological actions that can stabilize certain psychiatric state and/or pain states.  It is a good drug.

Unfortunately, there is a tendency for patients in methadone clinics to perceive that their treatment is being dictated to them.  It is always a problem when a person is dependent on their health provider.  They get angry and often do not trust their providers.

Methadone needs to be taken daily.  Patients will come in daily at the beginning of treatment but may come in less often as time goes by.  After three years, some may even have the option of monthly visits.  Frequency of attendence at the clinic had been set by federal regulation.  Regulations have become less stringent in the last few years but individual clinics may follow more restrictive protocols. 

In the last decade, Buprenorphine has become available.  Doctors in their offices can give it provided the doctors have met certain requirements.  The doctor is limited to 100 patients at one time.  Pharmacies will be able to fill prescriptions for the drug when written by these special physicians.  It is taken as a sublingual (under the tongue) tablet.  It has two forms: Subutex, which is pure buprenorphine, and Subuxone, which has a combination of buprenorphine and Narcan.  The Narcan is present to prevent patients from dissolving and injecting the medication.  Such abuse has been a problem in other countries. The Narcan will not be absorbed from underneath the tongue.

Buprenorphine will not solve all problems.  It is abused; all opiates are abused.  However, it helps many people as well.  It is safer to use than methadone; overdose is highly unlikely and intoxication is much less of a problem.  The physiologic withdrawal from buprenorphine will be less although the psychological symptoms of abstinence will still be a major problem.  I am excited about it, but only time will tell how well it will work.
12/25/2002

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