Authored by Christine Bradley, Co-Owner of The Genesis Center & Person in Recovery
Medication-Assisted Treatment (MAT), especially Methadone, is most often seen as the "last resort" to treat opioid addiction (opioids meaning: fentanyl, heroin, oxycodone, hydrocodone, morphine, etc.) yet, no matter how many lives Methadone or Suboxone has undoubtedly saved, stigma still surrounds these medications. That stigma is primarily based upon fears and assumptions, not based upon science and evidence.
There are many misconceptions, concerns, and myths surrounding MAT, which education about this particular type of treatment may help to break that stigma. Family members are often concerned about their loved one's health and future, only wanting what they believe to be best. This is because you may have heard some things about MAT that cause alarm; one of the most commonly voiced concerns is "Methadone is just trading one addiction for another." Many feel that the only way to truly recover from addiction is to abstain from all "mood-altering" substances... and this is still true. However, as science has progressed, we now understand that Methadone and Suboxone are not at all mood-altering substances.
Science has since unlocked that long-term opioid addiction, shuts down the brain's natural production of the "Four Hormones of Happiness." These hormones are dopamine, endorphins, serotonin, and oxytocin. Even though Opioid Use Disorder (OUD) effects all of these chemicals being naturally produced by the brain, endorphins and dopamine are the two most impacted.
THE SCIENCE OF OPIOID ADDICTION & WHY MAT WORKS
ENDORPHINS - The word "endorphin" comes from "endogenous", meaning, coming from within, and "morphine" - i.e., morphine from within. When endorphins interact with opioid receptors in the brain, you feel euphoric, elated, and free of pain. When opioid medications and fentanyl/heroin interact with opioid receptors, this also leads to euphoria and feelings of pleasure, but it is intensified immensely. Endorphins are chemicals that we all produce, these enable us to feel pleasure and happiness. Endorphins are released when we eat delicious food, enjoy a beautiful sunset, exercise, receive a "runner's high," make love, and even when we are injured, endorphins act as natural painkillers. The human body naturally produces endogenous opioids (endorphins) which function like hormones and activate opioid receptors in the brain. However, opioid drugs work much differently than endogenous opioids like endorphins. Unlike the opioids your body naturally produces, opioid drugs can have adverse side effects and can negatively affect the brain. When we flood our systems with exogenous opioids, our bodies recognize that we have plenty on board and cease to manufacture natural endorphins.
DOPAMINE - When opioids bind to opioid receptors, this stimulates our Dopamine Reward Center and encourages the brain to produce an excessive amount of dopamine. Dopamine relieves pain and increases pleasure. The brain naturally starts seeking to repeat the process that triggered that flood of reward. In addition, dopamine plays an important role in motivation and learning... because of this, the brain continues to seek out the source of the excessive dopamine, triggering opioid cravings. Prolonged opioid use trains the brain to rely on opioid-induced dopamine as the primary source of pleasure and reward. When this happens, the brain is tricked into believing it doesn’t need to produce dopamine by itself. This means the brain can ONLY produce dopamine when an outside drug is used.
These changes in chemical production and brain activity are many of the same reasons why The American Medical Association recognizes addiction as a true disease and once these changes in the brain have occurred, life becomes very difficult and painful. Even when the opioid use has ceased, the brain has already stopped natural production of endorphins and dopamine. The brain simply cannot just resume producing these chemicals. Some users (mostly short-term users) will be able to get their endorphins and dopamine back into natural working order, but this begins to gradually improve the longer we stay abstinent from the drug. However, for many, the damage done may be permanent. This has been confirmed in many scientific studies involving CT scans of the addicted brain. For these users, no amount of abstinence, will-power, therapy, meetings, or rehabilitation centers can undo an addicted brain that can no longer produce endorphins and dopamine in a sufficient quantity; not enough to allow a happy or fulfilling life. This is very similar to the way diabetics require supplemental insulin because the pancreas no longer manufactures insulin in a sufficient quantity. In addition, there are some people who have never had a fully functioning endorphin system before their drug use. These are often people who have struggled with depression or mental health disorders long before their opioid use. These people likely self-medicated with drugs in an effort to relieve their emotional or mental disrupt. For these people, abstinence-based recovery works poorly or not at all.
HOW DOES METHADONE TREAT OPIOID USE DISORDER (OUD)?
Methadone is a synthetic (man-made) opioid medication, used to treat the opioid addicted brain, developed in 1937 and on the market by 1943, it has some unique properties that make it extremely effective when treating OUD and managing withdrawal. It is a long-acting medicine, remaining active in the body for up to 72 hours after ingestion. It does not cause a "high" or euphoric state, like other short-acting opioids will cause. This is due to Methadone being taken up gradually by the brain, not sharply and suddenly. Methadone is also unique as it can act as a "blocker" against other opiates. Once Methadone binds to the opiate receptors in the brain, it is very difficult for other opiates to override this medication. To put this simply, Methadone almost acts like a cage, leaving other opiates unable to penetrate that cage... so patients soon realize their preferred opiate is no longer effective.
A stable Methadone patient, "stable" meaning, one who is not mixing this medication with other drugs (particularly benzodiazepines and/or fentanyl) and one who is on a medically appropriate dose will not be "high" or even sedated. These patients are able to work, operate a vehicle, care for children, and do anything else a non-medicated person can do. Their minds and judgement are not "clouded."
WHY DO I SEE METHADONE PATIENTS THAT APPEAR HIGH & WHY DOES OVERDOSE STILL OCCUR?
Some of these rumors may come from observing patients who are still continuing to use other drugs, or are taking more than their prescribed dose.
In fact, many overdoses involving Methadone are caused by people seeking the high they have come to expect with other opiates and after not achieving that high, they will take more and more, then mix Methadone with other drugs. Mixing methadone with other medications can be incredibly dangerous and may lead to respiratory depression.
According to the CDC, their most recent statistics prove that overdosing solely on Methadone is actually incredibly rare. In fact, in the year 2021, only 1.1% of Methadone related overdoses were caused by Methadone alone.
*THIS NUMBER INCLUDES OVERDOSE DEATH AND OVERDOSE SURVIVORS*
The CDC states that the rates of overdose deaths involving synthetic opioids, other than Methadone, [this includes fentanyl and fentanyl analogs] increased over 56% from 2019 to 2020. The number of overdose deaths involving synthetic opioids in 2020 was more than 18x the number in 2013. More than 56,000 people died from overdoses involving synthetic opioids in 2020. The latest overdose death counts [through June 2021] suggest an acceleration of overdose deaths during the COVID-19 pandemic.
*IN 2016 THE DEA RECOGNIZED FENTANYL AS A GLOBAL THREAT*
HOW CAN METHADONE ACTUALLY HELP TO HEAL THE ADDICTED BRAIN?
Methadone, when taken as prescribed, balances the chemicals in the brain so that the patient feels "normal," not impaired, similar to an antidepressant. Unfortunately, standard antidepressants generally do not work for those with dysfunctional endorphin systems because they target serotonin, not endorphins or dopamine. Methadone is also remarkable because it does not attach to all of the opiate receptors in the brain. Some are left open to encourage the brain to begin naturally producing dopamine and endorphins, if possible. This is why this medication has been proven to contribute to healing the addicted brain.
Methadone is commonly referred to as "replacement" or "substitution" therapy, and most think that this means it is replacing the heroin, fentanyl, oxycodone, hydrocodone, etc., Methadone does not replace the drug(s) a person was using. Methadone is only substituting or replacing the natural endorphins no longer being manufactured by an addicted brain. Again, this acts in the same way synthetic insulin substitutes for the natural insulin that is not produced by a diabetic's own organs.
Methadone treatment enables the patient to return to a normal, productive, and law abiding life in many cases. Even when the patient continues using other drugs, Methadone can lower their chances of contracting a disease, reduce the risk of overdose by decreasing their drug use, and enable them to seek a medical professional for assistance, counseling, and/or referrals on a daily basis.
HOW LONG SHOULD SOMEONE STAY ON METHADONE?
Addiction is a chronic and incurable disease and experts often recommend that a patient remain on MAT a MINIMUM of 3 years after they cease all illicit drug use. This is due to the average amount of time it takes for the opioid addicted brain to heal. But, recovery is NOT "one size fits all."
As fentanyl use continues to rise, the use of long-term MAT is likely needed to maintain recovery and some patients may want to stay on MAT indefinitely. Both options are okay.
Methadone has long been considered the "Gold Standard" in Addiction Medicine, as this treatment modality is statistically the most effective when treating OUD... far more effective than traditional rehabs and 12-Step programs alone. By no means is it the treatment of choice for every opioid user. However, if other treatment methods have failed many times over, there is little point in continuing the same thing and expecting different results "this time.”
HOW DO I SUPPORT MY LOVED ONE WHILE THEY ARE ENROLLED IN MAT?
Family support can be ESSENTIAL to successful recovery. If you find yourself asking questions or making statements like ["When are you going to get off of that stuff?" - "When are you going to start lowering your dose?" - "You just traded one addiction for another." - "Now you're addicted to Methadone."] you are doing more harm than good. These statements undermine treatment efforts and sabotage recovery and can even have deadly consequences. MAT patients should be made to feel proud about their recovery choices. There is nothing positive to be gained by attempting to force someone out of treatment before they are ready. So, please support your loved one's recovery and praise them when you see improvement, no matter how small it may seem to you, it's likely huge progress for that person and that positive reinforcement may be what they need to keep going.
Please remember, addiction is a disease of life or death. We do not tell people with diabetes, high blood pressure, epilepsy, etc. to discontinue their medications because we know when they do, their active disease will return. Why then, do we encourage MAT patients to do so, when their relapse rates are greater than 76%?
If you find yourself struggling to support your loved one's recovery, get involved in their treatment, but only when they want you involved. Until then, please seek out support groups for friends and family of addicts such as: