1. Medication Assisted Treatment Michael Ryan, LCSW, CASAC

2. What is Methadone Maintenance?

3. History of Methadone Maintenance
1962:
Dr. Vincent Dole while doing research at “Rockerfeller University on the disease of “Obesity” was prompted to read a book written by “Dr. Marie Nyswander titled “The Drug Addict”
Dr. Dole saw how some people would have uncontrollable cravings for food the same as a drug addict would have for drugs.

4. History of Methadone Maintenance
1963:
Dole and Nyswander collaborated their research.
Performed (15) month case study on the lives of (6) long time Heroin users.
They found that daily methadone use totally eliminated withdrawal symptoms, volunteers regained interest in work, family, school, and healthy recreation.

5. History of Methadone Maintenance
1965:
By 1965, Dole and Nyswander had completed studies on (22) heroin addicts, all outcomes were successful
1967:
Their work was highly recognized by the American Medical Association

6. Two Views of Opioid Dependence
Opioid addiction is caused by weak will, moral failing, other psychodynamic factors, or is predetermined.
View 1
Opioid addiction is an incurable disease. Treatment requires long term medical maintenance.
A maintenance program for those that are dependent upon opiates.
There are two different views of opioid dependence. One is the medical model, which is based on the premise that opiate addiction is a disease of the brain, just as diabetes is a disease, and both require long-term maintenance utilizing maintenance medicaiton.
The opposing view of opioid dependence is that it is an addiction caused by weak and morally compromised individuals, that CHOSE to use opiates.
In July, New York Mayor Rudolph Giuliani announced the end of methadone treatment programs in New York City within the next four years. The Mayor accused methadone treatment of substituting one addiction for another. He hopes to replace methadone programs with complete abstinence, a more "moral" means of treatment. Methadone, taken orally by recovering addicts to quell the desire for heroin, is used by about 40,000 persons in New York City (Rachel L. Swarns, "Mayor Wants To Abolish Use of Methadone," New York Times, July 21, 1998, p. B1; Beth Gardiner, "Giuliani Plans to Wean Methadone Users," Washington Post, August 23, 1998, p. A16). 6

7. Treatment Goal
“The goal of opioid treatment is to relieve withdrawal symptoms, reduce craving and permit normal functioning so that, in combination with rehabilitation services, patients can develop productive lifestyles.”

8. When opioids attach to the mu receptors, dopamine is released, causing  pleasurable feelings to be produced.

9. As opioids leave the receptors, pleasurable feelings fade and withdrawal symptoms (and possibly cravings) begin.

10. Opioids continue leaving the mu receptors until a person is in a mild-to-moderate state of  withdrawal .

11. Methadone then attaches to the empty opioid receptors, suppressing withdrawal symptoms and reducing cravings. 
When methadone is taken, it attaches to the empty mu receptor (opiate receptor) so that the withdrawal symptoms are not felt. Methadone, an opiate agonist, acts like morphine and other narcotic medications. Heroin addicts are physically dependent on opiates and will experience withdrawal symptoms if the concentration of opiates in their bodies falls below a certain level. In methadone maintenance treatment, patients receive enough methadone to ward off opiate withdrawal symptoms, but not enough to induce a narcotic high.

12. Methadone attaches firmly to the receptors
Methadone attaches firmly to the receptors.  At adequate  maintenance, methadone fills most receptors and blocks other opioids from attaching. 

13. How Much?
ENOUGH!

14. My dose isn’t “holding” me...
Environment
Stressors
Alcohol
Other drugs/medications
Vitamins
Urinary pH
Methadone Blood Levels

16. BENEFITS OF METHADONE TREATMENT
Marked decrease in illicit opiate use. In addition there is also a significant and consistent reduction in the use of other illicit drugs, including cocaine, and in the abuse of alcohol
Marked reduction of criminal activity
Marked decrease in emergency room visits
Increase rate of gainful employment
Marked decrease rate of transmission of HIV, Hepatitis (A, B, C, etc.) and other infectious diseases

17. Smart Statistic
The National Institute on Drug Abuse (NIDA) Treatment Outcome Study:
Heroin Use Decreased by 70%
Criminal Activity Decreased by 57%
Full-time Employment Increased by 24%

18. Methadone Myths Methadone gets into your bones
Methadone rots your teeth
Methadone makes you fat
Methadone is harder to kick
Methadone disrupts your sex life
Low doses of methadone are better than high doses
The shorter the methadone maintenance treatment the better
Pregnant addicts should not take methadone because it hurts their unborn baby
Methadone damages the liver
Methadone maintenance patients don’t need pain medication

19. Other Forms of MAT
Buprenorphine (Suboxone) Drugs that activate opioid receptors are termed opioid agonist. Heroin and methadone are opioid agonist. Opioids that bind to opioid receptors but block, rather than activating them, are termed opioid antagonist such as naltrexone and naloxone. l

20. Opioid partial agonist are drugs that activate receptors, but not to the same degree as full agonist.
Buprenorphine is an opioid partial agonist. It is the partial agonist properties of buprenorphine that make it safe and an effective option for treatment of opioid addiction.

21. Buprenorphine has sufficient agonist properties such that when it is administered to individuals who are not opioid dependent but are familiar with the effects of opioids, they experience subjectively positive opioid effects. These subjective effects aid in maintaining compliance with buprenorphine dosing in patients who are opioid dependent.

22. Buprenorphine occupies opioid receptors with great affinity and thus blocks opioid full agonist from exerting their effects.
Buprenorphine dissociates from opioid receptors at a slow rate. This enables daily or less frequent dosing of buprenorphine, as infrequently as three times per week in some studies.

23. Buprenorphine is abusable, consistent with its agonist action at opioid receptors. Its abuse potential, however, is lower in comparison with that of opioid full agonist.

24. Pregnant Women
The scant evidence available does not show any casual adverse effects on pregnancy or neonatal outcomes from buprenorphine treatment, but this evidence is from case series, not controlled studies.
Methadone is currently the standard of care in the United States for the treatment of opioid addiction in pregnant women.

25. Medication-Assisted Treatment for Alcohol Use Disorders (AUD)
Researchers continue to evaluate the efficacy of numerous compounds to treat AUD’s. To date, FDA has approved four medications for treatment of AUD’s:
1. Acamprosate (Campral)
2. Disulfiram (Antabuse)
3. Oral naltrexone (ReVia, Depade)
4. Extended-release injectable naltrexone (Vivtrol).

26. When implemented according to recommended guidelines, medication-assisted treatment combined with brief intervention or more intensive levels of nonpharmacologic treatment can do the following:
1. Reduce post acute withdrawal symptoms that can lead to a return to drinking (acamprosate’s hypothesized mechanisms of action).
2. Lessen craving and urges to drink or use drugs (naltrexone).

27. 3. Decrease impulsive or situational use of alcohol (disulfiram).
In addition, maintaining a therapeutic alliance with a healthcare practitioner can achieve the following:
1. Improve patients’ attitudes toward change.
2. Enhance motivation.
3. Facilitate treatment adherence, including participation in specialty substance abuse care and support groups.

28. Case Management
Case Management is a set of social service “functions” that helps a client access the resources they need to recover from a AOD abuse problem.
Because AOD abuse affects so many areas of the affected persons life, a comprehensive continuum of services promotes recovery and enables AOD abuse client to fully integrate into society as a healthy, AOD free individual.
Case Management is needed because in most jurisdictions, services are fragmented and / or inadequate to meet the needs of AOD abusing populations.