Opioid Maintenance Therapy: Questions and Controversies

Opioid maintenance therapy, or using a legal opiate to reduce a person's urge to take illicit drugs, has long generated controversy.
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Opioid maintenance therapy, or using a legal opiate to reduce a person's urge to take illicit drugs, has long generated controversy. Scientific evidence supports it as a practical, cost-effective strategy that prevents death and illness generated by street drug use and allows people who suffer from addiction to resume "mainstream" lives. But opponents argue that it simply replaces one addiction for another. So what's the real story?

Currently there are two kinds of opioid maintenance drugs, methadone and buprenorphine (often packaged under the brand names, Suboxone or Subutex. In addition to buprenorphine, Suboxone contains an added ingredient, naloxone, which is meant to deter abuse by sending users into withdrawal if they inject the drug). Methadone was first approved for use in substitution therapy under the Nixon administration, but due to concerns about its misuse, it continues to be highly regulated. To receive methadone, most people have to go to a clinic to receive a daily dose in liquid form, which they drink under the watchful eye of a nurse. Numerous barriers prevent people from seeking or maintaining methadone treatment, including lack of transportation, the inconvenience of daily visits to the clinic, and cost (no insurance company except Medicaid will cover the treatment.)

"I have to drive 45 minutes to a clinic in another city to get my methadone," says Chad of Durham, North Carolina. "Altogether, it's about three hours out of my morning, every morning, for years. Most people just can't do that."

Like many others, Chad takes methadone to reduce his craving for heroin. Although heroin and methadone are both opiate drugs with abuse potential, heroin provides users with a quick, potent high followed by a crash, while methadone is slow onset and long-acting. Ideally, methadone therapy allows opiate-dependent people to take just enough of the drug to avoid withdrawal symptoms and reduce the urge to take illicit opiates so that they may focus their energies on other pursuits.

Buprenorphine (bupe), also an opiate maintenance drug, was licensed for use in the U.S. in 2002 to circumvent the regulatory barriers around methadone access. Unlike methadone, bupe is not dispensed in regulated clinics, but prescribed by licensed physicians as a sublingual tablet or dissolvable film. Insurance companies usually pick up the cost, but many place limits on coverage - to the ire of medical providers.

"It's crazy for insurance companies to make up artificial limits," says Dr. Sharon Stancliff, MD, a buprenorphine provider and also the former Medical Director for a methadone clinic in New York City. "We don't place limits on blood pressure medication or diabetic insulin." She points out that in addition to helping reduce a person's craving for illegal drugs, opioid replacement therapy is shown to reduce the incidence of HIV transmission, drug overdose, and other morbidity and mortality related to illegal opioids.

Dr. Logan Graddy, MD, who runs an opioid maintenance clinic in Durham, North Carolina, agrees that artificial limits on treatment presents a serious impediment to recovery. "I recommend at least one year [on bupe] to my patients, but warn them that some might need it the rest of their lives. Many patients stay on the therapy at low doses because they feel that coming off completely can put them at risk for relapse."

Even though leading health organizations, including SAMSHA, WHO and UNODC promote opioid maintenance as a cost-effective tool to prevent HIV transmission and save lives from overdose and other drug-related activity, these programs continue to face criticism from traditional recovery groups, medical providers, and even users themselves.

"People taking methadone feel stigmatized," says Dr. Stancliff. "There is a pervasive idea that abstinence is the only answer to addiction even though we know it doesn't always work."

Medical providers who prescribe methadone and bupe often face stigma as well, but that doesn't stop providers like Dr. Stancliff and Dr. Graddy, who advocate for opioid replacement therapy because they have seen real results with their patients.

"A motivated patient on replacement therapy can make astounding changes in a year," Dr. Graddy says. "Many change careers, go back to school, and turn their lives around to where they might have been before they started taking drugs. I've seen miracles happen."

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