The Methadone Handbook,
(by Andrew Preston. 6th edition, edited for the US)
Methadone has been proven to be the most successful mode of treatment for opiate addiction by the National Institutes of Health.
Methadone can provide a useful period of getting used to life without heroin before becoming drug-free. Being stable in treatment can be the basis on which people start to build a way of life away from heroin use.
Prescribed methadone mixture has the advantages of being regular; long-acting; inexpensive; legal; non-injectable; and accompanied by counseling, medical care and other forms of help.
What are the benefits?
Methadone is one of the most researched medical treatments in the world. The studies clearly show that prescribed methadone can help people who are dependent on heroin to:
- stop using heroin (or greatly reduce the amount they take);
- stop injecting (or to inject less often and with less risk of HIV and hepatitis infection);
- improve their physical health and nutrition;
- stop committing crime to get money to buy drugs; and
- have more stable relationships and to get on better with their families.
This means that while on methadone treatment you have a chance to get things like debts, housing and relationships sorted out, so that you will have fewer pressures to use when you do come off opiates.
How long will it take?
There is no prescribed treatment length. It varies with each client depending on past drug use, emotional health, physical health, and support systems. The CDC’s most recent study of methadone maintenance therapy indicates that two years (which include stabilization, maintenance and detoxification) produces a higher success rate.
It is important to remember that you won’t get a heroin-like hit from methadone. Although they are both opiates, the effects of methadone are less intense and come on more slowly. Some people find the change takes some getting used to, others don’t find it a problem at all.
Taking more methadone will only increase the risk of overdosing.
Although methadone doesn’t always feel like a powerful drug, it is, and using heroin, alcohol or other sedatives (benzodiazepines) on top of methadone is dangerous and can easily cause overdose. Note that methadone is a respiratory depressant and slows the breathing. Alcohol and benzos have that same effect. Taking methadone in conjunction with either can lead to death.
The ideal dose at the start of treatment is one that:
- is enough to get you adjusted to taking methadone instead of other opiates;
- stops you suffering from withdrawals; and
- doesn’t over-sedate you.
There are a few rare effects that can occur in the first few days of treatment, such as a swelling of the ankles and feet, painful and swollen joints and a skin rash. Although these usually go within a few days, you should discuss any side-effects with your prescribing doctor.
The first few days
Methadone binds to cells in the liver, lungs and fat before moving back into the bloodstream to have an effect on you. This process is harmless and doesn’t damage the cells at all.
This means that you won’t get the full benefit of your dose during the first few days of treatment. It takes three or four days for these ‘tissue reservoirs’ to fill up and for the methadone to take full effect. You have much more methadone in your system four days into treatment than you do on day one or two. People often feel they haven’t enough methadone to hold them in the early days of treatment. Discuss this with your counselor and medical personnel. The risks of overdose are very high if you use other drugs in the early days of treatment.
Stability is the key
Methadone is more effective in helping people to stop using heroin when it is taken every morning. If you do this there should only be relatively small changes in the blood levels of methadone. Sporadic use of illicit drugs leads to “heroin days’ and ‘methadone days’ and this can result in very low blood methadone levels.
Everyone is different. So when someone says ‘methadone makes you sick/tired/itchy’ etc., what they mean is that methadone has that effect on them – it may or may not have a similar effect on you. You may experience only a few, some, or all of the effects listed below. You may experience them mildly or strongly.
There are some effects of methadone which are understood.
Its action on the brain can cause:
- a high/mood change that is less intense but longer lasting than heroin;
- controlling/levelling of emotions;
- nausea – if you vomit after taking methadone it is more likely to be caused by a psychological or medical problem (or, if you drink, by alcohol) than by methadone – get your doctor to check it out;
- Slower, shallower breathing (which is only dangerous in overdose scenarios;
- reduced cough reflex; and
- reduction of any physical pain.
Its action on nerves that control involuntary functions usually causes:
- small pupils;
and can cause:
- dryness of the eyes, nose and mouth;
- reduced blood pressure; and
- difficulty in passing urine.
In some people methadone causes the release of histamine (which is normally only released in allergic reactions) by rupturing the cells that produce and store it. This is not an allergic reaction. Histamine release can cause:
- flushing of the skin; and
- narrowing of the air passages in the lungs.
Methadone may also cause or contribute to:
- absent or reduced menstrual cycle
- reduced libido
- reduced energy;
- a heavy feeling in your arms and legs; and
- a craving for sweet foods.
The mechanisms that cause these effects are not always clear and some (such as no energy, reduced sexual desire and reduced periods) can be caused, or made worse by, other things in life.
The things methadone doesn’t do…
Because it is a long-acting drug, methadone does not give the same sense of a ‘hit’ as heroin: most people can take it once a day without experiencing serious withdrawal symptoms. In people tolerant to a stable dose, methadone won’t affect:
- vision; and
Long-term effects – Methadone doesn’t damage your:
- liver (but see below if you have liver damage);
- reproductive system; and
- immune system.
Methadone does not damage any part of the body as it passes through.
The liver breaks down (metabolizes) methadone into a form which can pass harmlessly through the kidneys into the urine.
However, in people who have a liver that is very seriously damaged (by illnesses such as hepatitis B or C or by alcohol); the extra work for the liver can cause overdose or liver failure. The danger is greatest at the start of treatment, when the dose increases, or if the condition of the liver deteriorates further.
It is true to say that methadone, even if taken for many years, causes no direct physical damage and is usually much healthier than being dependent on illicit opiates. People who are opiate dependent (whether they are on methadone or not) can experience problems such as changes in sex drive and constipation.
Tolerance is the way the body adapts in order to cope with the regular presence of some drugs. Once a tolerance has developed it takes bigger doses to achieve the same effect. The tolerance you have built up to other opiates is transferred to the methadone when you start taking it.
If you detox, or don’t take opiates for a few days, tolerance will quickly reduce. After a break it is easy to overdose on an amount that, at one time, might not have seemed to have any effect at all.
One of the reasons why methadone is prescribed is that tolerance to it usually builds up very slowly.
The body builds up tolerance to most of the effects individually and at different rates. So your tolerance to one effect – such as feeling sedated – may have built up while you were taking heroin to the extent that you don’t feel sedated at all when you start the methadone. But another effect – such as a dry mouth – may still be with you after an extended period of time. The effects to which people rarely develop a tolerance are:
- itching; and
- small pupils.
If you need to be prescribed painkillers, your tolerance to opiates can cause problems. If it does, it may help to ask the doctor treating your pain to talk to the doctor treating your drug dependence.
Constipation is one of the effects of opiates to which people rarely develop a tolerance, and chronic constipation can cause serious long-term problems.
So, if you will be taking methadone over a long period, it will be really helpful if you can include lots of fruit and vegetables and alcohol-free drinks in your diet every day.
If constipation is a problem, talk it over with your doctor – especially if you are thinking about using laxatives. Some types of laxatives can be very helpful, but those which work on the muscles make things worse in the long term.
Like all opiates, methadone is not good for your teeth because it can restrict the production of saliva which is one of the body’s natural defenses against plaque – the commonest cause of tooth decay. Methadone is no worse for your teeth than eating sweets or taking sugar in tea and coffee.
It also helps to:
- try and cut out (or reduce the amount of) sugary foods in your diet;
- clean your teeth morning and night and after meals
- (use your own toothbrush as there is a hepatitis C risk from using other people’s);
- use dental floss; and
- chew sugar-free gum.
Like all opiates, methadone can inhibit or remove the desire to have sex. In men it can affect the ability to get an erection. These effects vary from person to person – and loss of desire to have sex can happen in relationships for a number of other reasons. However, this can be one of the most difficult side-effects of methadone treatment to live with. If it is a problem for you, it may be helpful to talk things through with your drug worker.
If you do have a sexual relationship, using condoms not only helps to prevent pregnancy, but can also protect you and your partner against HIV, hepatitis B and other sexually transmitted diseases.
Hepatitis B and HIV and other sexually transmitted diseases live in body fluids: mainly blood, semen and vaginal fluid. They are passed on when the infected body fluids of one person pass into the blood of another person. The skin of the vagina, anus and penis is thin and easily damaged so this can happen when people have penetrative sex without a condom.
This happens even more easily when injecting equipment is shared. Hepatitis C is a virus that can be caught easily through sharing injecting equipment or paraphernalia such as water, filters, spoons, etc. but is not usually transmitted sexually.
Women and methadone
A large proportion of women who use opiates experience reduced or absent periods.
This may be due to opiates reducing the levels of hormones that control menstruation. However, periods can also stop because of stress, poor diet and/or weight loss.
It is important to remember that even if you are not having periods you can still get pregnant.
At any time during your treatment, but especially at the start or during detox (when desire to have sex may increase), you may get pregnant.
Apart from protecting you from hepatitis and HIV and other sexually transmitted diseases, condoms can also stop you getting pregnant – even when you aren’t having periods.
Advice on condoms and other forms of contraception should be available locally from drug agencies, family planning clinics, sexual health services, HIV/AIDS services and GPs.
If you think you might be pregnant, don’t worry that the methadone may have harmed the baby. There is no evidence to show that there is any additional risk to the development of the baby while you are on a stable dose of methadone.
Stopping suddenly can be dangerous for you and the baby and should only be done under medical supervision.
Sometimes the stress and pressures of pregnancy make it hard to stop using and you could decide not to detox. If you are physically dependent on opiates, being stable on methadone is better for the baby and you than being unstable on illicit drugs, especially if you are injecting.
Many babies have been born to mothers using methadone, and large studies have shown that methadone does not damage the unborn child. But the baby may experience withdrawals, which may not start immediately after the birth.
The baby can be detoxed in a few days – under medical supervision – without any long-lasting effects. If the baby is withdrawing, make sure the doctors know. Allow the baby to rest as peacefully as possible between regular feeds and avoid bright lights, which may irritate him/her.
You must not try and detox the baby yourself, or ever give methadone to a child – you could easily kill it!
There are many benefits to breastfeeding and you can breastfeed while on methadone. Small amounts of methadone in breast milk can pass to the baby, but opinion varies as to how much the mother has to take before this happens. If this does happen it will reduce or prevent withdrawals in the baby after birth.
If you can take your methadone home, make sure children can’t get to it – as they have no tolerance even very small amounts can kill them.
This is because methadone can make them:
- stop breathing;
- vomit; and
- choke on their saliva or vomit because they can’t swallow while unconscious.
To help prevent such accidents, you should keep methadone in bottles with a child-resistant cap. These caps can save lives but they are not enough on their own – even very young children can sometimes get them open.
If you take methadone home and you have children, you should:
- keep it in a locked box at all time with the key in a different location
- talk to your children about the dangers of all medicines.
And make sure methadone is never kept:
- in a fridge;
- under the bed; and
- in a car glove box.
Studies have shown that for people with HIV, methadone is much better than illicit opiate use. This is especially true for injectors because injecting can accelerate the progression of HlV-related illness by affecting general health and introducing bacteria directly into the bloodstream.
If you are on methadone, the doctors managing your HIV need to know because methadone interacts with some anti-viral treatments.
Methadone and other drugs
Although methadone doesn’t react with or affect most other prescribed drugs, always check with a pharmacist if you get a prescription for something else or are buying over-the-counter medicines.
If you go to the dentist or a doctor other than your prescribing doctor for treatment, tell them you are prescribed methadone.
This is especially important if you need treatment for:
- HIV; and
- anxiety or poor sleep.
If you take buprenorphine while on methadone, you may go straight into withdrawals because it is a different type of opiate and it will expel methadone from the opiate receptors.
You will also go straight into withdrawals if you take the drug naltrexone – which is sometimes prescribed to help people stay off opiates.
Methadone blocks the receptors in your brain that heroin and other opiates have to fit into in order to have an effect. So, if you have any methadone in your system, heroin may have a reduced effect or none at all. If you try to take enough to get a hit, you run the risk of overdosing.
Taking any sedatives in conjunction with methadone can be dangerous as they make each other more effective and increase the risk of OD or potentially fatal respiratory
Methadone and alcohol boost each other’s effect. Use of alcohol with methadone can lead to depressed respiration and can be fatal.
Not taking your prescribed methadone dose can result in withdrawal symptoms which include:
- a high temperature but feeling cold, with goosebumps alternating with
- feelings of anger and/or anxiety;
- jerking arms and legs;
- disturbed sleep;
- feeling or being sick;
- running eyes and nose;
- pains in muscles, bones and joints; and
- yawning and sneezing.
Most physical withdrawal symptoms are probably caused by the body continuing to overproduce a chemical called noradrenaline. Noradrenaline is responsible for controlling many automatic body functions – such as digestion. The overproduction is caused by the body taking time to realize that its noradrenaline receptors are no longer blocked by opiates. Opiates may also reduce the secretion of the body’s natural opiates called endorphins. This may partly explain why people still feel anxious, cold and/or have difficulty sleeping for a long time after coming off opiates. Because methadone is a longer-acting drug, most people find the withdrawals longer-lasting than with heroin. But there isn’t much in it and the mechanisms of readjustment are essentially the same whether you’ve stopped methadone or any other opiate. The problems associated with coming off opiates are not all physical and, in the long term, looking for non-drug solutions is important if you want to stay drug-free.
During a slow detox most people find it takes about four days to get over the worst of the withdrawals when they first drop to a lower dose, but it can take up to 14 days.
Each time you take a drop in dose there are several things you can do to help make the adjustment easier:
If you can, plan to take it easy for a few days after each drop;
- keep things as stress-free as you can;
- look after yourself – stay warm, eat well and drink plenty of alcohol-free
Detoxing isn’t just about physical withdrawals. It is about dealing with the emotional and psychological issues in ending therapeutic relationships. Utilize counseling and support systems during this time.
It is important that opiate users remember that:
- as little as 10mg can kill a small child;
- a mouthful can kill a teenager;
- less than 50mg can kill a non-tolerant adult