Don’t Forget Methadone

By Jessica Gregg MD 01/12/17

Acceptance of ambivalence is one of the most powerful aspects of methadone treatment. Recovery from addiction is a long process, often requiring several attempts and various wrong turns.

A hand holding red liquid in a clear cup
Methadone provides patients with an opportunity to pause.

The World Health Organization considers methadone one of the world’s “Essential Medicines.” Methadone maintenance has a long history of clinical efficacy and remains arguably the most effective treatment available for opioid addiction, reducing not only illicit drug use but “HIV infection, crime and death.” Despite this track record, methadone maintenance has a poor public image, one that may have contributed to the lack of attention it received in the recently-enacted 21st Century Cures Act, which provides significant funding for methadone’s “less potent, but more discreet, cousin,” buprenorphine. Addiction Medicine physician Jessica Gregg argues for more funding for methadone treatment and describes a case in which methadone, as opposed to buprenorphine, proved the right medication for one of her clients…Richard Juman, PsyD

When I started Ashley on methadone she was ambivalent, at best.

“I don’t even want to be here,” she said. What she wanted was to take buprenorphine, methadone’s less potent, but more discreet, cousin. She’d had it prescribed before, and she felt like it helped—though not enough to stop her from using heroin. Eventually, when enough of her drug screens showed that she was still using, her doctor told her he thought she needed to try a different strategy. He stopped prescribing the buprenorphine and referred her to our methadone clinic.

“I won’t be coming here for long,” she told me. “So keep my dose low.” She said that she just needed a little help through her current rough patch and then she would be on her way. Also, she informed me, I shouldn’t expect to see her every day. She didn’t want anyone to know she was on methadone so she couldn’t ask for a ride to the clinic, and she didn’t have a car herself. Taking the bus required two transfers and money she didn’t always have. We’d see her when we’d see her.

Not surprisingly, Ashley struggled at first. She would come in for her medication one day and then miss a couple days in a row. During the periods when she was absent, she would use heroin.

But she never disappeared altogether. She’d show up at least twice a week, visit her counselor, and occasionally check in with me. Some days she argued with other patients in the dosing line and would storm out. Other days she told her counselor funny stories about her stupid dog, or her brother’s band, and she’d stick around for a while. Gradually, she started to show up more. Even more gradually, she stopped using heroin. She also stopped dating guys who used drugs and were mean to her. She got a job, and kept it. 

Eventually, on methadone, Ashley’s life got much, much better.

Ashley’s story isn’t particularly exciting. She never hit “rock bottom,” she never had a spiritual awakening, and she didn’t suddenly become a better person. She didn’t even stop using right away. Like many people who do well on methadone, hers is a story of showing up, trying, failing, and showing up again. It's the story of a slow, uneven trudge toward recovery.

I tell this unexciting story because the U.S. Senate recently approved the 21st Century Cures Act, which includes $1 billion for opioid prevention and treatment programs. A large portion of that money is expected to fund medications like buprenorphine and naltrexone, both of which can be prescribed from a doctor’s office, and both of which have proven to be extremely effective in the treatment of opioid use disorders. But in the rush to provide medication to the people who need it, it is important to also remember methadone.

Methadone treatment must be expanded as well.

Methadone is an opioid, like morphine or codeine. Or heroin. If a patient takes more than she needs, she may overdose, and if she takes it every day, her body will become dependent upon it. But when taken properly by someone addicted to opioids, it can also eliminate drug cravings for an entire day. Methadone is associated with reductions in illicit drug use, HIV infection, crime and death. It decreases mortality from opioid use disorders by up to a stunning 75 percent. In fact, its effects are so remarkable that the World Health Organization has placed it on its list of “essential medications.”

Yet it seems no one loves methadone. When someone addicted to opioids declares her intention to get help, the world loves her: "Thank God." "I’m here if you need me." "Call anytime." When someone addicted to opioids declares that the help involves methadone, the reaction is much different. I have lost count of the number of times patients, counselors, and even other physicians have told me that methadone treatment is just a case of “trading one addiction for another.” I’ve had patients barred from 12-step meetings or excluded from other drug treatment programs because they are taking methadone, and I’ve had patients decide to taper their medication because friends or parents or partners tell them if they are taking methadone, they’re still just a junkie.

And patients learn quickly. Some arrive at the clinic as early as 4:30 in the morning, heads ducked down, baseball caps low on their foreheads. They get their medication, get out and go to work, terrified that they will be seen by anyone they might know driving or walking by. In the caste system of the addiction and recovery worlds, individuals on methadone are untouchables.

It is unconscionable.

It is also understandable. Methadone is messy, and it is far easier to reject an individual who is taking it than to explore why she takes it, and whether and how it is helping. Unlike buprenorphine and naltrexone, methadone for the treatment of addiction can only be dispensed from a federally regulated opioid treatment center—a methadone clinic. For various reasons, some of these facilities do an inadequate job of supporting patients under their care. Patients may be herded into long dosing lines where they wait, sometimes for hours, becoming increasingly sick, irritable, and poorly behaved. They may also be required to meet regularly with counselors who are too overwhelmed with large caseloads to remember their names, much less the details of their lives. The existence of these poorly run clinics is a serious problem. But it is not a reason to dismiss methadone’s efficacy, and/or to scorn the individuals who benefit from it.

Methadone can also be misused. Some patients seek doses that are higher than they need, or use their methadone in dangerous combination with alcohol or sedating drugs like benzodiazepines. Clinics have procedures in place to prevent those behaviors, but they happen anyway. Even if they are not misusing their medication, patients on methadone may be ambivalent about ceasing their illicit drug use. Committing to abstinence before beginning methadone treatment isn’t a requirement, and patients can remain in treatment even if they continue to use.

But this is what people need to understand: acceptance of ambivalence is also one of the most powerful aspects of methadone treatment. Recovery from addiction is a long process, often requiring several attempts and various wrong turns. Many times, just the act of showing up at a clinic and considering the possibility of change is a critical step forward. And as patients try these new habits on for size, the effects of the methadone itself allow patients the opportunity to pause, silence their howling cravings, and reengage with the rest of their lives, as quickly or as slowly as they need.

On medication, an accountant can focus on her spreadsheets again, the guy who steals bikes for drug money starts working instead of stealing, a dad starts to make it to his kids’ games, and the woman who used opioids to forget her horrific childhood has sober moments that feel okay and thinks there may be hope after all. Ashley trusts her counselor, starts to come to clinic, gets a job, and finds a home for herself. All of those behaviors are part of recovery. And sometimes, within the process of recovery, ambivalence becomes a commitment to abstinence.

So, sure, methadone maintenance can be messy. It can also be a boring, uninspiring, plodding slog toward change. But when it works well—and it often works well—it provides patients with a potent tool for recovery and it offers time, alive and without cravings, for them to make the changes they need to move forward. Drug overdose is the now leading cause of accidental death in the United States, mostly due to opioids. So, in the spirit of the 21st Century Cures Act, and in honor of all those individuals whose lives have been saved by the medication, or could have been, I make this request: please don’t forget methadone. We need it.

Jessica Gregg received her undergraduate degree from Stanford University, her medical degree from the University of New Mexico, and her doctorate in medical anthropology from Emory University. She is also a diplomate of the American Board of Internal Medicine and a diplomate of the American Board of Addiction Medicine. Dr. Gregg has clinical practice in Portland, Oregon and has published widely about addiction and the current opioid epidemic, including recent articles in the Annals of Internal Medicine, the Washington Post, and Time Magazine.

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Dr. Jessica Gregg is a diplomate of the American Board of Internal Medicine and a diplomate of the American Board of Addiction Medicine and has clinical practice in Portland, Oregon. You can find Dr. Gregg on Linkedin. Her full bio can be viewed here.