Methadone Use and Abuse
What is Methadone?
OUD is a significant health problem that affects about 2 million people in the US.2 There were 70,000 drug overdose deaths in 2017, and opioids accounted for over 47,000 of those deaths.3 This figure includes overdoses resulting from the abuse/misuse of both prescription and illicit opioids.
In 2015, 502,000 people aged 12 or older reported having misused methadone in the past 12 months. This number decreased to 346,000 in 2016. In 2016, 8 deaths involved methadone, and there were 1217 case reports involving only methadone.4
What Does it Do?
It helps reduce withdrawal and cravings during detoxification from opioid addiction (medication-assisted detoxification). The drug is also used for months or years to control cravings in some opioid-dependent people. This is known as methadone maintenance treatment (MMT).
Over the past few years doctors have been prescribing the drug to treat moderate to severe pain. In 2017, there were 2.6 million prescriptions, which was a slight decrease from 2.9 million in 2016.4
The drug comes in the following forms:
Poweder (for prescription compounding)
Two brands of the drug are available on the market. They are Methadose and Dolophine.
A team of German scientists first developed the drug. They were looking for a pain reliever less addictive than morphine.
Two German scientists – Max Bockmühl and Gustav Ehrhart – discovered a substance that would later be called methadone (in the US). They called it Hoechst 10820 or polamidon.
The US acquired the rights to polamidon and named it methadone.
The US introduced the drug as a pain medication.
US Public Health Service hospitals started using oral forms of the drug to treat opioid withdrawal.
Methadone maintenance treatment (MMT) was developed as a measure to control the post-World War II heroin epidemic in NYC.
The use of MMT for opioid addiction expanded rapidly throughout the US.
The US government published regulations to monitor the use of the drug.
The government adjusted the regulations, allowing doctors to use the drug more effectively.
The FDA warned consumers that using the drug for pain management may cause fatal heart and breathing problems, and also deaths. Moreover, the FDA asked doctors to monitor the dose more closely.
The use of 40-mg dispersible tablets was restricted to hospitals and authorized opioid addiction treatment facilities.
How Does Methadone Work?
It works in the same way as morphine, heroin, and other opioids. They all activate opioid receptors. Although it occupies and activates these opioid receptors, it does so more slowly than other opioids and, in an opioid-dependent person, treatment doses do not produce euphoria.
As a Treatment for Opioid Addiction
Unlike heroin, methadone has a long half-life. The half-life is the time required to clear half of the drug from the bloodstream. When people suddenly stop taking heroin, they experience withdrawal symptoms.
Methadone mimics the effects of heroin by binding to opioid receptors. In this way, it helps relieve withdrawal symptoms and reduce cravings. It is one of the most effective treatments for opioid addiction, especially heroin addiction.
As a Pain Medication
The drug alters pain signals in the brain and affects the activity of some brain chemicals known as neurotransmitters. These include dopamine, noradrenaline, and acetylcholine. The drug also acts on other receptors involved in pain signaling, such as the NMDA receptors.
Is Methadone Addictive?
All opioids are addictive. Nonetheless, using methadone differs from heroin or illegal opioid addiction.
Using the drug under medical supervision is safer than using heroin or other illegal opioids.
MMT administers the drug by the oral route. This is safer than injecting heroin, which carries the risk of HIV transmission.
Substituting illegal opioids with methadone decreases the risk of death due to opioid overdose. People on MMT are five times less likely to die from infectious diseases and three times less likely to die from overdoses.8
Studies show that people on MMT are less likely to be involved in criminal activity. They are also more likely to participate in talk therapy.
It’s a member of a class of medications called opioids or narcotics. Opioids are powerful pain medications. They work by blocking pain signals in the brain. They also enhance feelings of wellbeing and pleasure. In the US, the most frequently used opioids are:
Prescription opioids, such as OxyContin and Vicodin
Fentanyl, a nonnatural opioid 50 to 100 times more powerful than morphine
Heroin, an illegal drug with no FDA-approved medical use
Where is Methadone on the Schedule?
It’s a Schedule II controlled substance. The Drug Enforcement Administration (DEA) categorizes substances based on their abuse potential. Substances in Schedule II have high abuse potential. Abusing these substances can cause severe dependence.
Other drugs on this schedule are:
Oxycodone (OxyContin, Percocet)
Fentanyl (Sublimaze, Duragesic)
Is Methadone Safe?
It’s safe and effective when used under medical supervision. The drug is the most widely studied treatment option for opioid addiction. Numerous studies have shown that using it is safer than using other drugs or illicit substances.
Yet, the drug has a high overdose risk. This is because the effective dose is close to the toxic dose. Thus, taking a dose slightly higher than the recommended one can cause potentially fatal effects. Because of its high overdose risk, the drug is dispensed only through government-approved opioid treatment programs (OTPs).
People who wish to use methadone safely and effectively should:
Avoid drinking alcohol while they are using the drug.
Inform a physician if they are also taking other drugs that may interact with methadone, such as anxiety drugs.
Always take the drug as prescribed and never take an extra dose to make up for a missed dose.
Call 911 immediately if a higher dose is taken.
Never share drugs with others or take others’ drugs.
Keep the drug out of children’s reach.
What are Some Street Names?
The drug goes by several street names, such as:
Chocolate Chip Cookies (with MDMA)
How Is Methadone Used/Abused?
For detoxification or maintenance, only specialized clinics called methadone clinics can dispense the drug. For pain management, the drug can be purchased from a licensed pharmacy. The drug is either injected or swallowed.
Doctors use the drug to control withdrawal symptoms. The duration of use is generally 5 to 14 days.
Written consent from the patient is required before MMT begins. A doctor begins treatment with the lowest possible dose and observes the patient’s signs about 3 hours after the first dose. The starting dose can range from 10 to 30 mg. Patients should continue taking the same dose for three days. For those who experience withdrawal, the dose may be increased by 5 mg every three days.
Multiple dosing (up to 3 times a day) is necessary to control pain.
Drug abuse refers to the inappropriate use of a drug. It can include taking more than the recommended doses, using another person’s prescription, or taking the medication for a longer duration than recommended.
According to a report by SAMHSA, in 2007,9
- 78% of methadone emergency department (ED) visits involved abuse, misuse, or nonmedical use 78% 78%
- 10% involved using the drug for detoxification 10% 10%
- 7% involved adverse reactions or side effects 7% 7%
- 5% involved suicide attempts 5% 5%
People sometimes mix methadone with other substances such as sleeping pills, anxiety drugs, marijuana, and alcohol in an attempt to increase the relaxing effects.
Is it Safe to Use Methadone During Pregnancy?
It’s use during pregnancy is safe. The National Institute on Drug Abuse says that the drug can be safely used during pregnancy with little risk to mother and infant. With methadone treatment, pregnant women who have had used heroin are:
Three times less likely to use heroin.
Three times more likely to stick to treatment.10
Methadone use in pregnancy can cause neonatal opioid withdrawal syndrome (NOWS) in newborns. NOWS may occur in 60 to 80% of newborns exposed to opioids during pregnancy.11 Nonetheless, NOWS is treatable, and only severe cases require further treatment with an opioid. Infants with NOWS may have low birth weights. Nevertheless, over time, their weights tend to be similar to those of children born without NOWS.
What are the Signs and Symptoms of Methadone Abuse?
Abuse causes several noticeable physical symptoms and behavioral changes. These include:
Physical Signs of Abuse
Extremely constricted pupils
Behavioral Signs of Abuse
Withdrawal from previously enjoyed activities
Poor performance at work or college
Frequent attempts to get more and more of the drug
Buying the drug from online vendors
Effects of Methadone
Methadone shows its effects about 30 minutes after a pill is ingested. The blood levels of the drug peak within the next 3 hours and become stable after 24 hours.
The following short-term effects are seen in people taking the drug:
Enhanced feeling of wellbeing
Change in body temperature
Decrease in pupil size
Slowed breathing rates
Decreased sensitivity to pain
Low blood pressure
A doctor must be consulted immediately if a patient experiences any of these symptoms:
Swollen lips, tongue, or throat
Hallucinations (feeling things that are not there)
Abnormally fast heartbeats
The side effects of long-term methadone use can include the following:
Sexual problems including impotence in men
Irregular periods in women
Enlarged breasts in men
Problems remembering things or objects
Problems learning new things
Sleep problems such as difficulty falling asleep
Unintentional weight gain
Pain, redness, and swelling at the site of infusion (not applicable to oral use)
The rate of methadone overdose deaths increased six fold from 0.3 persons per 100,000 in 1999 to 1.8 per 100,000 in 2006. The death rates remained stable in 2007 and then dipped by almost 40% to 1.1 in 2014.12
Still, an overdose is the leading risk associated with methadone abuse. The drug has been involved in the majority of prescription opioid deaths in recent years. For example, in 2014, methadone contributed to about 1% of all opioid prescriptions. However, it was involved in nearly 23% of all prescription opioid deaths.12
Emergency department (ED) visits involving methadone increased by over 42% from 48,864 in 2004 to 69,506 in 2007. Deaths increased almost sevenfold from 786 in 1999 to 5,416 in 2016. During the same period, heroin deaths increased by 6% from 1,964 to 2,090.9
An overdose is more likely to occur during the initial stages of MMT. Also, the risk is high if someone is using the drug with other depressant drugs such as sleeping pills or anxiety drugs.
The signs of an overdose can include:
Weak and slow pulse
Fainting and inability to regain consciousness
Foaming at the mouth
Naloxone is an antidote for opioid overdose. Methadone stays in the system for extended periods due to its long half-life. Thus, multiple doses of naloxone are required to reverse the effects of an overdose. Immediate hospitalization and close monitoring are essential to recovery.
It’s a powerful and highly addictive medication. Abrupt discontinuation can cause severe withdrawal. Always speak with a doctor before ending methadone use.
The length of MMT depends on various factors. These include the patient’s drug use behavior and individual response to treatment. Nonetheless, most experts agree that at least a 12-month period of treatment is necessary. Some people may need MMT for several years.
Managing Withdrawal from MMT
There are several approaches to withdrawal from MMT, including:
Dose tapering. Withdrawal symptoms begin to appear as the dose drops below 20 mg per day. Doctors do not usually recommend reducing the dose if the reduction makes symptoms more severe. Thus, it is critically important to consult a person on MMT before considering dose tapering.
Transfer to other medications. Depending on the severity of withdrawal, doctors may prescribe naloxone or buprenorphine. Most notably, naloxone treatment should begin only 14 days after a person has stopped using methadone.
Aftercare. A person requires supportive care for up to 6 months after stopping methadone use. Aftercare comprises medical, psychological, and economic interventions. These interventions aim to reduce relapse rates and treatment dropout rates.
Withdrawal symptoms occur when the use of an addictive substance is discontinued. Initially, withdrawal from methadone causes flu-like symptoms. However, withdrawal symptoms are usually more severe than flu symptoms and tend to last longer. Most withdrawal symptoms appear within 30 hours after the last use. These symptoms can include:
Within 72 hours after the last use, some symptoms may become worse, such as:
Pain in muscles
Withdrawal symptoms peak during the first week and then gradually decline. Nonetheless, low moods, tiredness, and sleep problems may persist for many weeks. The risk of relapse is high during withdrawal. For this reason, a doctor may continue prescribing lower doses to prevent relapse.
The doctor can also prescribe other medications to relieve withdrawal symptoms. These include buprenorphine, clonidine, and naloxone.
Treatment for Abuse/Addiction
Methadone addiction is a severe long-term disorder. Thus, treatment at specialized rehab centers is required to discontinue drug use safely. Rehab centers provide the following services:
People with severe addiction usually need to stay in the rehab center for several months. An inpatient facility has detox, rehabilitation, and support programs. These programs are tailored to meet a person’s individual needs. Staying in an inpatient facility encourages a person to stay away from situations that may trigger drug use. After a person becomes stable, they may be switched to treatment at an outpatient facility.
People enrolling in an outpatient program do not need to stay in the rehab center. Instead, they can visit the center for a predetermined duration each day. Outpatient services are more flexible than inpatient services but may carry a higher risk of relapse.
Counseling and Psychiatric or Psychological Consultation
A comprehensive treatment program has provisions for psychiatric or psychological consultation. This is critical, as many people with addiction also have psychiatric conditions. Besides, counseling helps people stay away from drug use for longer durations.
Follow-up Care and Aftercare
Recovery is a continuous process. Aftercare for methadone addiction begins once a person completes treatment at a rehab center. A team of doctors and psychiatrists prepare the person for a successful transition to the community. They teach ways to control cravings, identify triggers, and continue living a drug-free life. Periodic follow-up visits are necessary to prevent relapse.
Parting Questions and Answers
What is the Best Substitute for Drug Abuse: Suboxone or Methadone?
According to researchers from the UK, methadone might be a better substitute for opioid addiction compared to buprenorphine (Suboxone). This is because the former is cheaper, has superior efficacy, and, most notably, is safe for use during pregnancy.13
What is Methadone’s Use in Palliative Care?
Methadone may be used in palliative care because of its low cost and longer duration of action. Many small trials show that methadone may be as effective as other opioids in pain management. Moreover, it may cause fewer episodes of constipation compared to other opioids.14