This letter will attempt to address some of the common concerns for those of you who have loved ones on MMT (Methadone Maintenance Treatment). There are many misconceptions and common misunderstandings surrounding addiction and this type of treatment, which education and knowledge about the treatment may alleviate. Methadone, unfortunately, is surrounded by unfair stigma and prejudice based on fears and assumptions, not science and medicine. Family members quite naturally are concerned about their loved one's health and future and only want the best for them. They may have heard some things about MMT that cause them alarm. One of the most commonly voiced concerns is that MMT 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. At one time this was thought by most to be true, but methadone is not a mood altering medication at all. Science has discovered that with long term opiate addiction (opiates meaning heroin, fentanyl, oxycodone, hydrocodone, morphine, etc.), the brain's natural production of dopamine and endorphins are shut down. So let us break down how this occurs: 

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ENDORPHINS - Endorphins are the chemicals that we all have to enable us to feel pleasure and happiness. These chemicals are released when we eat delicious food, make love, enjoy a beautiful sunset, exercise (runner's high), or even when we are injured, as natural painkillers. The human body naturally produces endogenous opioids which function like hormones and activate opioid receptors in the brain. For example, endorphins are endogenous opioids. 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 medication and heroin interact with opioid receptors, they can also lead to euphoria and feelings of intense pleasure. But opioid drugs work 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 (outside) opiates, our bodies recognize that we have plenty on board and cease to manufacture our own natural endorphins.

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DOPAMINE - When opioids bind to opioid receptors that regulate reward, they encourage the brain to produce an excessive amount of dopamine. Dopamine relieves pain and increases pleasure. The brain naturally seeks to repeat processes that trigger this reward. In addition, dopamine plays an important role in motivation and learning. Because of this, the brain continues to seek out the source of dopamine, triggering opioid cravings. Continued opioid use allows the brain to begin to rely on opioid-induced dopamine as a primary source of pleasure. When this happens, the brain is tricked into believing it doesn’t need to produce dopamine on its own. 

 

A brain without endorphins or dopamine causes: 

• Depression or hopelessness 

• Anxiety

• Anger

• Exhaustion or lack of motivation

• Poor concentration

• Shaking hands and other tremors

• An inability to feel pleasure

• Sleeplessness

• Short-term memory loss

• Difficulty managing daily tasks

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These changes in chemical production and brain activity are the reasons why the American Medical Association recognizes addiction as a true disease. This happens to all opiate users and life becomes very difficult and painful. Remember, even when the opiate use has ceased, the brain has already stopped all natural production of endorphins and dopamine. The brain cannot just resume producing these chemicals. Some patients, especially those with short-term addiction histories, will be able to get their natural endorphins back into proper natural working order again after only a few weeks or months of abstinence and that production will begin to gradually improve. However, for many, the damage done is permanent. This has been demonstrated in many scientific studies involving CT scans of the addicted brain. For these patients, no amount of abstinence, group therapy, meetings, rehabilitation centers, will power, or good intentions will undo the fact that their brains simply will no longer produce dopamine and endorphins in a sufficient quantity to enable them to live a normal, fulfilling, and happy life. This is in fact very similar to the way in which diabetics require supplemental insulin because their pancreas no longer manufactures insulin. In addition, there are some patients who have never had a normally functioning endorphin system, patients who have struggled since birth with crippling depression. These are the people who likely became addicts in an effort to relieve their constant emotional and mental misery. For them, too, abstinent based recovery works poorly or not at all. 

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This is where MMT comes in. Methadone is a synthetic (man-made) opioid drug, used to treat pain and addiction. It has some unusual properties that make it well suited to addiction treatment. It is a long acting drug, remaining active in the tissues for up to 72 hours after ingestion. It does not cause the high or euphoria caused by other, short acting opiates because it is taken up gradually by the brain, not suddenly and sharply. In fact, many overdoses involving this drug are due to people seeking the high they have come to expect with other opiates and after not achieving that high, they will take more and more. A stable methadone patient who is not mixing the medication with other drugs (particularly benzodiazepines, which is a very dangerous mixture) and who is on a medically appropriate dose will not be "high" or sedated. These patients are able to work, operate a vehicle, care for children, and do anything else a “normal” person can do. Their minds and judgement are not "clouded". Some of these rumors may come from observing patients who are abusing other drugs, or are taking more than their prescribed dose.

Methadone, when properly administered and taken, balances the chemicals in the brain so that the patient feels normal, not impaired. Unfortunately, standard antidepressants generally do not work well for those with dysfunctional endorphin systems because they target serotonin, not endorphins or dopamine. Methadone is also unique in that it does not attach to all the opiate receptors in the brain, leaving some open to encourage the production of natural endorphins if possible. This may contribute to the healing of the addicted brain. Methadone is commonly referred to as "replacement" or "substitution" therapy, and most think that this means it is replacing the heroin, oxycodone, fentanyl, hydrocodone, etc. Methadone does not replace the opiates the patient was abusing. In fact, it is replacing the natural endorphins no longer being manufactured by the patient's brain, in the same way synthetic insulin substitutes for that not being made by the diabetic's own organs. Methadone treatment enables the patient to return to a normal, productive, law abiding life in many cases... and even when the patient continues abusing other drugs it may 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 referrals on a daily basis.

However, for many (not all) MMT patients, long-term therapy (even lifelong) may be needed to maintain recovery. Addiction is a chronic, incurable disease. We do not tell diabetics, blood pressure patients, epileptics, etc. to discontinue their medications because we know that if they do, the active disease will return. Why then, do we encourage recovering and thriving MMT patients to do so, when the relapse rates for those discontinuing MMT is greater than 90%? Methadone is the most effective modality of treatment for opiate addiction available today--far more effective than traditional rehabs and 12 step groups alone. By no means is it the treatment of choice for every opiate addict. However, if abstinent methods have failed many times over, there is little point in continuing to try the same thing expecting different results "this time.”

Most experts recommend that a patient remain in MMT a MINIMUM of 3 years after they cease illicit drug use. At that time, if, and only if, the PATIENT themselves wishes to begin a taper program, one can be attempted. Tapering must be done on a slow and gradual basis--no more than 10% of the dose every 2 - 4 weeks. If the person begins experiencing severe cravings or withdrawals, they should stop and return to an adequate dose until symptoms subside. If the person relapses, this should not be seen as failure or weakness, but only as evidence that they may require ongoing therapy to control their symptoms. Family support is ESSENTIAL to the patient's successful recovery on MMT, and continued questions like --"When are you going to get off of that stuff? It's just a crutch!"-- undermine treatment efforts and sabotage recovery, leaving the patient confused, sad and frustrated instead of feeling proud and happy at the improvements in their lives. Addiction is a deadly disease and there are few effective treatments for it, so please support your loved one's recovery efforts and praise them when you see improvements. Please remember, addiction is a disease of life or death. There is nothing positive to be gained by forcing them off of treatment before they are ready. 

 

If you would like more information about MMT, please seek out reputable sources such as:

 SUBSTANCE ABUSE & MENTAL HEALTH SERVICES ADMINISTRATION

AMERICAN SOCIETY OF ADDICTION MEDICINE

SHATTERPROOF | ENDING THE STIGMA OF ADDICTION