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Chemical Dependency Research Working Group

II.
Methadone Maintenance Treatment

Methadone Maintenance Treatment and Clinical Issues
by
Herman Joseph

Methadone maintenance treatment has been thoroughly researched and carefully evaluated for almost three decades. It has received more scientific scrutiny and evaluation than any other medical treatment or human service program (Ball & Ross, 1991; Brecher, 1972; Des Jarlais, Joseph, Dole & Schmeidler, 1983; Dole & Joseph, 1978; Dole & Nyswander, 1976; Dole & Nyswander, 1965; Dole, Nyswander & Warner, 1968; FDA, 1989; Gearing, 1970; Gearing & Schweitzer, 1974; GAO, 1990; Gordon, 1970; Hartel, Selwyn, Schoenbaum et al, 1988; Joseph & Dole, 1970; McLellan, Arndt, Metzger, Woody & O'Brien, 1993; Newman & Cates, 1977; Parrino, 1992; Simpson, 1981; Stimmel, Goldberg, Cohen & Rotkopfe, 1978). Most evaluations have shown that, when correctly implemented, the treatment is capable of producing remarkable improvements in patients who were previously dysfunctional heroin addicts. Methadone maintenance patients throughout the world have been restored to productive lives, relations with families and children have been reestablished, many have furthered their educations, obtained employment and improved their physical and mental health. Nevertheless, contrary to scientific evidence, methadone maintenance treatment remains a controversial issue among substance abuse treatment providers, public officials and policy makers, the public at large and the medical profession itself.

Methadone was synthesized in Germany during World War II as a substitute for morphine when supplies of opium from Turkey were cut off by the United States and their allies. The drug was brought to this country after the war and studied in 1946 at the United States Public Health Hospital in Lexington, Kentucky. It was found to be similar in its effects to morphine but possibly longer acting. Clinical research showed that the drug could be used effectively in the treatment of the opiate abstinence syndrome by substituting it for morphine and slowly tapering down the dose over a period of about one week to ten days (Brecher, 1972). Until the development of methadone as a maintenance medication in 1964, the primary use of methadone in the treatment of addiction was to withdraw addicts from heroin, a procedure that differs from maintenance and exploits only a few of the potentially useful properties of the medication.

By the late 1960s in New York City, heroin related mortality was the leading cause of death for young adults between the ages of 15 and 35 (Joseph & Dole, 1970). Serum hepatitis cases related to injection of narcotics with contaminated needles were increasing. A record number of addicts were being arrested for drug-related crimes, including possession, sales, robbery and burglary, and overcrowded jail facilities with no medical care to ease withdrawal were creating havoc (Brecher, 1972; Inciardi, 1988; Joseph, 1992; Joseph & Dole, 1970). By 1968, the Manhattan County Jail for Men (known as the Tombs) was racked by riots because of the severe overcrowding and lack of medical care for arrested addicts. With the medical and legal professions calling for a reevaluation of American narcotic policies in respect to treating addicts, the climate was more favorable to challenge the Bureau of Narcotics' anti-maintenance position.

In 1962, Dr. Vincent P. Dole, a specialist in metabolism at the Rockefeller University was appointed to look into the situation by Dr. Lewis Thomas, chair of the Narcotics Committee of the Health Research Council of New York City. After studying the scientific, public health and social ramifications of the addiction problem in the city, Dr. Dole received a grant from the Health Research Council to establish a research unit at the Rockefeller University to investigate the feasibility of opiate maintenance.

In preparing for his research he read the book, The Drug Addict As A Patient by Dr. Marie E. Nyswander (1956), a psychiatrist who had extensive experience treating addicts. She had served as a physician at the U.S. Public Health Service Hospital in Lexington, Kentucky, treated addicts in private psychiatric practice, established a store front for treating addicts in East Harlem and was the psychiatrist for the Musicians Clinic, a program which treated addicted musicians (Hentoff, 1969). Dr. Nyswander believed addicts could be treated within the medical profession rather than through incarceration in the criminal justice system. However, she believed that many would have to be maintained on narcotics in order to function, since the majority relapsed despite many hospitalizations, withdrawal and therapy (Brecher, 1972; Courtwright, Joseph & Des Jarlais, 1989). Dr. Nyswander joined Dr. Dole's research staff in 1964. At the same time, a young clinical investigator, Dr. Mary Jeanne Kreek, completing her training in internal medicine and neuroendocrinology at the New York Hospital-Cornell Medical Center, was also recruited to join the research team.

Maintenance with low doses of morphine was administered to the first two patients who had used narcotics for at least eight years and had extensive criminal histories related to their addictions (Brecher, 1972; Dole & Nyswander, 1967). Both had previously attempted therapy and had withdrawn from heroin several times, only to relapse. Since morphine has a half life of four to six hours, the patients required injections at least four times per day. As tolerance developed to the morphine, they required increasing amounts administered at more frequent intervals to remain comfortable. And they remained preoccupied with drugs, apathetic and sedated from the narcotizing effects of the morphine.

The researchers knew that morphine's effects are similar to heroin. It was not a good choice as a maintenance drug. While criminal behavior might be reduced because the drug would be obtained legally, the patient would remain dysfunctional. Impairment would result from morphine's narcotizing qualities and the short half life of the drug requiring several injections per day. With the development of tolerance increasing amounts would be needed to remain comfortable over a short period of time. Similar results were obtained for other short-acting narcotics such as hydromorphone, codeine, oxycodone and meriperidine (Dole, 1988; Dole, 1980; Dole, Nyswander & Kreek, 1966). A distinct disadvantage of most of the short-acting narcotics was that to be maximally effective they had to be injected.

With the failure of short-acting narcotics to properly maintain patients, the research revolved around the choice of a possible maintenance medication that was orally administered and long acting. Methadone appeared to have these qualities and was selected based on the observations of addicts being withdrawn from heroin and research into its use as an analgesic in the experimental treatment of pain (Dole, 1988; Joseph & Dole, 1970; Kreek, 1973). In 1964, the technology was not yet available to measure the blood levels of heroin, morphine and methadone. The results concerning the outcome of methadone as a maintenance medication depended on the observations and insights of the researchers.

Once methadone was established as a proper maintenance medication at doses of 80 to 120 mg/day, eight important findings were noted. These findings would constitute the basis of a maintenance program capable of permitting otherwise intractable addicts to function normally within society (Dole, 1988; Dole, 1980; Dole & Nyswander, 1965; Dole, Nyswander & Kreek, 1966; Gordon, 1970; Joseph & Dole, 1970; Kreek, 1978; Kreek, 1973; Newman & Cates, 1977).

1. The narcotic craving described by addicts as a major factor in relapse and the continued illegal use of heroin was relieved. This is perhaps the most important property of methadone, thus allowing addicts to live a stable life.
   
   
2. Tolerance to the narcotic effects of all opiate class drugs is blocked. At doses beginning at 80 mgs/day tolerance is held at a high enough level to block the euphoric and tranquilizing effects of all opiate class drugs. Should the patient administer any opiate, including methadone, either orally, through injection or by smoking the effect will be blocked. Also, beginning at 80- mg/day the patient is protected from overdose and respiratory depression if large amounts of narcotics should be administered. This protection is strengthened at higher doses of 100 mg/day or more.
   
   
3. Stabilized patients do not experience any euphoric, tranquilizing or analgesic effects. Their affect is clear and enables them to socialize and work normally without the incapacitating properties of short-acting narcotics such as morphine or heroin.
   
   
4. There is no change in tolerance levels. Therefore, the same dose of methadone can be prescribed to a patient for an indefinite period of time (e.g. 20 years). This effect contrasts with other opiates such as morphine and heroin whose dose must be increased.
   
   
5. Methadone can be taken orally by patients once per day. This eliminates the use of needles for injection and immediately reduces the risk of HIV infection and other serious conditions caused by using unsterile needles.
   
   
6. Studies undertaken over the past two decades, primarily by Dr. Mary Jeanne Kreek of The Rockefeller University, and corroborated by other scientists throughout the world have established the long-term medical safety of methadone maintenance treatment (Kreek, 1992; Kreek, 1987; Kreek, 1986; Kreek, 1978; Kreek, 1973; Kreek et al, 1972; Novick, Richman, Friedman et al, 1993). There are no toxic effects, somatic damage or functional deficits associated with or attributable to methadone for patients who are stabilized at appropriate doses including those receiving over 100 mgs/day, who are not heavily abusing other drugs (e.g., alcohol and cocaine), and who have remained in continuous treatment for up to 18 years. There are minimal nontoxic side effects, such as constipation, that can be treated; excessive sweating that in most cases subsides over time; and decreased libido and, in some males, delayed orgasm that normalizes within the first few months of treatment or with dose adjustment (Kreek, 1978; Kreek, 1973). Methadone is safe for persons who have been properly stabilized, since methadone can be lethal for nontolerant persons who will require emergency treatment with narcan for about 24 to 36 hours if they should accidently ingest a dose prescribed for a tolerant patient.
   
   
7. Motor coordination, reaction time and intelligence tests to determine if patients can function normally have been administered to patients maintained on high doses of methadone (over 80 mg/day). No significant differences have been found between maintained patients and the non-maintained controls. On some tests the patients even exceeded the performance of the controls. Patients' intelligence scores also improve over time. The conclusion was that patients are able to function within normal parameters when prescribed the high doses of methadone necessary for maintenance (Gordon, 1970).
   
   
8. It should be understood that tolerance to the analgesic effects of methadone are quickly achieved and methadone patients can be treated for severe acute and chronic pain by administration of morphine, as would any other patient (Dole, Nyswander & Kreek, 1966). Morphine, or any other short-acting narcotic, can be given at regular or more frequent time intervals and at higher levels in accordance with the patient's tolerance. Mixed agonist/antagonist drugs such as Talwin, Nubain and Stadol should never be administered to a methadone patient. Methadone will block the euphoric and tranquilizing effects of short-acting narcotics however, the analgesic or pain killing properties of short-acting narcotics will be able to penetrate the blockade phenomenon and the patient will receive the necessary pain relief (Payte, Khuri, Joseph & Woods, 1994).

In conclusion, methadone when prescribed as a maintenance medication functions as a normalizer for a deranged physiology and not as a mood altering narcotic substitute (Dole, Nyswander & Kreek, 1966; Joseph & Dole, 1970). Also, methadone maintenance is a corrective but not a curative regimen.

Initially the criteria for admission to methadone conformed to the needs of a strict research protocol (Brecher, 1972; Gearing & Schweitzer, 1974; Joseph & Dole, 1970). Only addicts between the ages of 21 and 40 were admitted. The upper age limit was based on the theory that addicts begin to mature out of addiction over the age of 40. The applicants had to be addicted to heroin for at least four years and have relapsed after previous attempts at withdrawal from heroin and treatment. Addicts who were polysubstance users, including alcoholics and those afflicted with major psychiatric and medical problems such as tuberculosis, were not considered eligible. Initially women of child bearing age and pregnant addicts were not permitted because the effects of methadone on the reproductive system and developing fetus were not known and the researchers were investigating a new medical procedure (Joseph & Dole, 1970). As methadone treatment proved to be successful and medically safe, the admission criteria were gradually modified.

Today, the regulations of the Food and Drug Administration (FDA) allow heroin addicts to be admitted with a one year addiction history including current use (FDA, 1993). The lower age limit has been reduced to 16, however applicants between the ages of 16 and 18 must have two prior episodes of either withdrawal from heroin or drug free treatment and parental consent or be declared emancipated before being admitted. The upper age limit has been eliminated since it is now known that while a group of addicts do mature out the majority do not. It has subsequently been learned that untreated addicts have high death rates at young ages, may be incarcerated or become seriously alcoholic (Dole & Joseph, 1978; Joseph & Appel, 1985). Women of child bearing age and pregnant women are now accepted and, with special medical justification, a pregnant woman can be admitted with an addiction history of slightly less than one year. Applicants with major medical conditions and polysubstance abuse problems including alcoholism are now eligible for treatment (FDA, 1993).

In 1965, under the guidance of Dr. Ray Trussell, the New York City Commissioner of Hospitals, the initial research project was expanded and transferred to the Manhattan General Hospital in New York City where a heroin withdrawal program had previously been established. An impartial unit to evaluate the expansion and progress of methadone treatment was created at the Columbia University School of Public Health and Administrative Medicine with Dr. Frances Rowe Gearing as the chief of evaluation. The unit's work was reviewed by an independent committee composed of physicians and scientists with Dr. Henry Brill as its chairman. The committee made recommendations for further evaluation, research and expansion of the program (Joseph & Appel, 1992; Joseph & Dole, 1970). Thus, methadone maintenance received rigorous scrutiny and evaluations with follow-up studies that continue to this day.

No matter what country, ethnicity, sex, education or economic background of the patients, studies evaluating methadone have been consistent. The following summarizes the findings from major studies conducted over the past approximate three decades.

1. When placed on an adequate dose of methadone (e.g., 80 to 120 mgs/day), heroin use by patients is significantly reduced within the first two months of treatment and eventually either eliminated or significantly curtailed with time in treatment (Ball & Ross, 1991; Cooper, 1992; Dole & Nyswander, 1965; Dole, Nyswander & Kreek, 1966; GAO, 1990; Schuster, 1989).
   
   
2. Crime related to drug use is reduced significantly within the first year of treatment and the reductions continue with time in treatment. These trends persist irrespective of cities, culture or era. A study of 1,870 methadone patients admitted to treatment in New York City in the 1960s showed that arrest rates decreased 95 percent when compared to arrest rates three years prior to entering and three years after entering treatment (120 vs 5.5 arrests per 100 man years) (Gearing, 1970; Gearing & Schweitzer, 1974). The city of Hong Kong introduced methadone treatment for its addicts in 1976 and subsequently there was an 85 percent reduction in the number of heroin addicts admitted to prisons in the city from 1976 to 1980 (Newman & Cates, 1977). In 1985, a study of methadone programs in Baltimore, Philadelphia and New York City found a 79 percent decrease in the number crimes committed by patients during their first six months of treatment as compared to their last episode of addiction (Ball & Ross, 1991). Criminal behavior declined the longer patients were in treatment.
   
   
3. Productive behavior as measured by employment, school attendance or homemaker status increases with time in treatment. When the program was first implemented in 1964, the patients were able to obtain jobs in manufacturing, trades and construction. Within the first year of treatment, about 60 percent were socially productive (Dole & Joseph, 1978). These trends continued into the 1970s. However, with the change in the employment market from manufacturing to service jobs, the lower levels of education among new admissions, the periodic economic downturns, increased homelessness, cocaine/crack use and HIV infection among the patients, productivity and employment levels for patients declined from a high of about 60 percent in the late 1970s to about 28 percent in 1994 (Gearing & Schweitzer, 1994; Joseph, 1992; Kreek, 1992; Randall, 1994).
   
   
4. Poly drug abuse and alcoholism affect a significant minority of the patients. Generally speaking, those patients that are dually addicted when entering methadone treatment continue poly drug abuse and alcoholism, unless they are treated for these conditions. Prior to the AIDS epidemic, the physical effects of alcoholism were the major causes of death for patients in treatment and the second major cause of death after heroin overdose in the posttreatment period (Joseph & Appel, 1985). However, with the high prevalence of HIV infection among methadone patients in treatment HIV infection has become the major cause of death (Joseph & Springer, 1990)
   
   
5. Studies by Ball and Ross (1991) and McClellan and colleagues (1993) demonstrate the need for psychosocial services in methadone programs to ensure their maximum potential in helping patients. In the 1980s and currently in the 1990s, new admissions present serious social, psychological and medical problems to clinics. Among the problems are homelessness, cocaine/crack addiction, alcoholism, HIV infection, drug resistant TB, mental illness, chronic unemployment, poor education and a host of social problems (Joseph, 1992; Joseph & Appel, 1992).
   
   
6. In an important study, McLellan and colleagues (1993) have shown that while methadone alone is effective for some patients, the addition of services results in better treatment outcomes for a greater number of patients. All patients in the study were maintained at 60 mgs/day or more of methadone and dose was increased as needed if use of opiates persisted. Patients were assigned to one of three service components: (1) Minimal care included an adequate dose of methadone but no other services. (2) Standard care included an adequate dose of methadone plus counselling. (3) Enhanced services included an adequate dose of methadone plus counseling, on-site medical/psychiatric/employment services and family therapy.
   
   The study found that patients involved in enhanced program services showed significant improvements in social adjustment and employment status, with significant decreases in alcohol and cocaine use and illegal activity. McLellan also reported that when dysfunctional patients receiving minimal care were given standard care, the improvements in reduction of illicit opiate and cocaine use were significant and occurred rapidly within a period of four weeks. Patients receiving enhanced care in the McLellan study made significantly greater improvements than those receiving standard or minimal care.
   
   
7. A study of socially productive methadone patients (employed, in school or homemakers) by Joseph and Des Jarlais (1980) shows that patients are able to hold positions across the spectrum of the job market. To qualify for an interview in this study, patients had to be in treatment for at least four years, not involved with illicit drugs or criminality for at least three years, and be employed outside the field of drug treatment, drug-related research or drug-related social services. Furthermore, they had to have addiction histories of four or more years.
   
   It was found that among the 47 who met these criteria and volunteered for taped interviews at three programs the daily methadone doses ranged from 5 to 100 mg/day with patients at the low dose level withdrawing from the program. About 54 percent of the patients interviewed were receiving between 60 and 100 mg/day. There were no particular relationships between dosage and salary levels. The patients were primarily employed in jobs and professions in private industry. Some examples of jobs at different dose levels included an attorney who was withdrawing (5 mgs/day), an architect (30 mgs/day), a rock musician (30 mgs/day), two truck drivers (40 and 100 mgs/day), an auto mechanic (40 mgs/day), a window cleaner on skyscrapers (60 mgs/day), a producer of documentary films (70 mgs/day), two housewives (20 mgs/day and 90 mgs/day), a computer technology worker (90 mgs/day), a chef in a gourmet restaurant (100 mgs/day) and a road construction laborer (100 mgs/day).
   
   At the time of the interviews 72 percent of the patients had one continuous episode of treatment, 21 percent were in their second episode of treatment and 6 percent in their third episode of treatment. Patients with two or more episodes of treatment relapsed to use of heroin during their posttreatment periods in spite of their good adjustments, including gainful employment, and had to re enter treatment.
   
   All of the patients were acutely aware of the stigmatization of being maintained on methadone. For over half of this group, no one at work knew about their addiction history or enrollment in methadone treatment. In cases where somebody did know, it was usually an immediate supervisor, personnel administrator or a trusted colleague. This pattern of concealment was carried over into their family and social lives. Old friends who were aware of the patient's prior addiction history may or may not have known about their current treatment. Patients, however, rarely told new friends about their prior addiction or methadone treatment. The patients also concealed their enrollment in methadone treatment from members of their own immediate families. Parents, siblings and children may not have been told about methadone and were under the impression that the patients were cured and had "kicked their habits." The exceptions were spouses who were aware of the patients' histories and enrollment in treatment.
   
   Only 13 percent socialized with other methadone patients. The great majority socialized with family and "straight people. Since the patients did not use other drugs and took their methadone as directed, concealment of their methadone status was made easier by the absence of narcotic effects, the ability to work and interact socially without impairment.

The work of Drs. Dole and Nyswander has had a great impact on the treatment of heroin addicts in the United States today. First, they brought the treatment and care of addicts into the medical profession, albeit a controlled isolated and highly regulated clinical system. Nevertheless, this was an incredible accomplishment in itself, considering the lack of understanding of opiate addiction as a metabolic condition at that time and the 50 year history of treating heroin addiction as a criminal justice problem. However, it must be emphasized that methadone maintenance did not expand because society wanted to provide treatment for heroin addicts. To the contrary, the main concern was reducing the number of crimes committed by addicts. That included the curtailment of the spread of addiction-related infections, such as HIV and hepatitis.

Their second accomplishment was the launching of the first and most effective harm reduction program. Harm reduction takes a public health approach toward the problem of drug use with pragmatic strategies to reduce the harm that drugs do to the individual and society. The emphasis on drug enforcement and punishment as the primary strategies to control drug use is replaced with education, prevention and treatment. Today the methadone maintenance program has been expanded and is the major public health program for the treatment of heroin addition in the United States. From 1964 through 1994 there have been over approximately 2,000,000 patient-years on methadone maintenance treatment in the United States. Presently, there are about 115,000 persons known to be enrolled in approximately 850 methadone maintenance treatment programs in 40 states. Also, methadone maintenance programs are expanding throughout the world to prevent the transmission of HIV.

The major findings of follow-up studies of discharged methadone patients in the United States and Europe have found that a large majority are unable to maintain abstinence and eventually relapse to daily heroin use. Despite the fact that many of these studies were conducted prior to the homelessness, AIDS and crack/cocaine epidemics, they are remarkably consistent across ethnic, racial and cultural differences. These studies are important since they show that the majority of discharged patients were unable to make sustained good post-treatment adjustments in a less threatening era. The studies include those by Ball and Ross, 1991; Cushman, 1980; Des Jarlais, Joseph, Dole and Schmeidler, 1983; Dole and Joseph, 1978; Dole and Nyswander, 1976; Gearing & Schweitzer, 1974; Gunne, Gronbladh and Ohlund, 1993; Joseph and Dole, 1970; Simpson, 1981; Stimmel, Goldberg and Cohen et al, 1978.

The overwhelming evidence is that the majority of patients who leave methadone maintenance, irrespective of their type of discharge (favorable vs. unfavorable) and their individual prospects for successful abstinence, eventually relapse to daily use of narcotics. Today, persons who are HIV- and leave methadone treatment are at high risk of contracting HIV after leaving treatment because of the high rate of relapse to drug use.

1. Death rates for patients who leave treatment are more than twice the rate of patients who remain in treatment. Excessive posttreatment deaths are usually associated with factors involving the injection of heroin (e.g., overdose and transmission of infectious diseases) and violence. Death rates are excessive irrespective of the type of discharge, but former patients with favorable terminations have lower death rates than those discharged for other reasons. Within the past six years AIDS has become the major cause of death in many methadone programs. In some areas it is estimated that about 50 percent of new admissions to methadone maintenance treatment are infected with HIV.
   
   
2. In most studies about 80 percent of the former patients relapse to use of heroin and/or other narcotics within approximately two years after leaving treatment. Excessive, life threatening use of alcohol and other drugs (e.g., cocaine) effects a substantial number of former patients who may not relapse to heroin. In one study, only eight percent of the former patients were abstinent from daily use of narcotics, non-opiate drugs and life threatening alcoholism after one episode of methadone treatment.
   
   
3. Gender, ethnicity and level of education did not predict posttreatment daily narcotic use. While these factors may influence decisions to enter treatment, they appear to have little or no influence in preventing relapse to daily heroin use after leaving treatment.
   
   
4. Years of heroin use, time in treatment, abuse of drugs while in treatment, employment status and type of discharge were the factors that contributed most to predicting posttreatment heroin use. Patients who were able to remain abstinent after leaving usually used heroin for shorter periods prior to entering treatment than those who relapsed. They also remained in treatment longer, did not abuse other drugs, were fully employed and received a favorable termination from treatment.
   
   
5. Although social rehabilitation is important for a positive posttreatment adjustment, the duration of a heroin addiction may also be a crucial factor for patients to remain abstinent after terminating treatment. Patients in good standing with longer histories of heroin addiction have higher probabilities for relapse than patients in good standing with shorter periods of addiction. Also, longer durations of methadone treatment contribute to posttreatment abstention, implying that pharmacological and biological factors may also influence post treatment outcomes. These include the type of narcotic (heroin-short acting vs. methadone-long acting), the route of administration (oral vs. injection), and the circumstances under which a narcotic is administered. Even under the most optimistic conditions, patients in good standing still have a high probability of posttreatment relapse. Therefore, there should be no moral judgement on the part of treatment staff, family, friends or employers if patients in good standing relapse after leaving treatment. Patients who relapse after leaving treatment should be allowed to reenter the program without feeling guilty or a failure.
   
   
6. In the Des Jarlais, Joseph, Dole and Schmeidler (1983) study, using the various factors to predict post treatment abstention, it was found that about 70 percent of those who met optimal conditions for discharge, relapsed to daily use of heroin in comparison to the 90 percent who relapsed when conditions were less than optimal.

These studies emphasize the importance of retaining patients in methadone treatment. Even patients whose individual prospects for successful abstinence are optimal are likely to eventually relapse to daily use of heroin. Factors that contribute somewhat to successful outcomes after discharge from treatment are favorable discharge, stable life style and a shorter period of illicit heroin use. Programs which encourage patients to withdraw from methadone are not setting policies based on scientific evidence, nor are they serving their community.

Patients who do decide to withdraw from methadone and leave treatment should be given the facts regarding their prospects for abstinence and encouraged to return to treatment should they relapse to heroin use. Patients who do return to treatment because they have relapsed should never be made to feel guilty and every effort should be made to help them understand that this is the nature of their disease and that their decision to return to treatment was positive.

Numerous studies have indicated that the most effective range for methadone maintenance is between 80 to 120 mg/day at the beginning of treatment (Ball & Ross, 1991; Ball, Lange, Myers & Friedman, 1988; Cooper, 1992; Dole, Nyswander & Kreek, 1966; GAO, 1990; Hartel, Selwyn, Schoenbaum et al, 1988; Kreek, 1992; Kreek, 1986; Payte & Khuri, 1992; Schuster, 1989). Methadone dose should be determined, like the prescribing of any other medication, through consultation between physician and patient. During the later stages of treatment the dosage may be either lowered or raised depending on the requirements of the patient.

The original research upon which methadone maintenance is predicated was based upon a dose range of about 80 mg to 120 mgs/day (Dole, Nyswander & Kreek, 1966). For a dose of methadone to be effective three types of phenomena must be met:

1. Relief of drug craving that begins at about 60 mgs per day for most patients (Dole, Nyswander & Kreek, 1966; Kreek, 1988; Kreek, 1986).
   
   
2. A high enough tolerance level must be reached to block the narcotic effects of all opiate drugs, including methadone itself if it should be administered. This blockade effect begins at about 70 to 80 mgs/day and the effect is strengthened at the higher doses (100 to 120 mgs/day) (Dole, Nyswander & Kreek, 1966; Kreek, 1988; Kreek, 1986).
   
   
3. The patient must be able to function normally without the impairing effects of narcotics namely, euphoria, tranquilization and analgesia. The patient must be able to maintain physical coordination and dexterity (Dole, Nyswander & Kreek, 1966; Kreek, 1988; Kreek, 1986).

At high doses (e.g. 100 mg/day), patients have a degree of protection from heroin overdose. At this level they are less likely to succumb to respiratory depression if they should administer illicit narcotics to challenge the blockade (Dole, Nyswander & Kreek, 1966). This is especially important at the beginning of treatment, when patients may experiment with heroin to test the effectiveness of the medication (Hartel, Selwyn, Schoenbaum et al, 1988). For the patient entering treatment methadone dose is the most critical element to ensure the patient's later adjustment.

All clinical surveys implemented in the United States and world wide validate the importance of prescribing an adequate and effective dose (80 to 120 mg/day) of methadone (Ball, Lange, Myers & Friedman, 1988; Ball & Ross, 1991; Blix & Grondbladh, 1988; Caplehorn & Bell, 1991; Cooper, 1992; D'Aunno & Vaughn, 1992; Dole & Joseph, 1978; GAO, 1990; Kreek, 1992; Payte & Khuri, 1992; Schuster, 1989). The following studies confirm the clinical findings of the original study by Drs. Dole, Nyswander and Kreek (1966) and reported in the article "Narcotic Blockade."

1. In a review of the literature, Hargreaves (1983) indicated that patients appear to do better on the higher doses within the range of 50 to 100 mg/day. This is especially true at the beginning of treatment when patients need full pharmacological support. The review recommended that NIDA encourage state agencies to allow local programs to prescribe methadone up to a dose level of at least 100 mg/day.
   
   
2. Watters and Price (1985) reviewed 44 methadone maintenance programs and determined that dose was the single most important factor related to retention in treatment. The higher the dose, the longer patients remained in treatment.
   
   
3. Hartel and colleagues (1988) undertook what is probably the largest and most sensitively designed study at Montefiore Hospital in the Bronx. Hartel, an epidemiologist, examined the records of approximately 2,400 methadone patients over a 15-year period. She identified a trend line that started at about 70 mgs/day and began to achieve real clinical significance at 80 mgs/day. With the higher doses, from 80 to about 100 mg/day, patients had better retention in treatment, less HIV infection and less polysubstance use, including cocaine and crack.
   
   
4. A comprehensive study by Ball and Ross (1991) of six programs located in Baltimore, New York City and Philadelphia demonstrated that patients reduced their use of IV heroin by 71 percent compared with their pre-admission drug use. The study followed the IV heroin use of 407 patients over a period of one month and found that the higher the methadone dose, the less the frequency of heroin use. About 27.9 percent of the 204 patients receiving 45 mg/day or less used heroin, compared to only 5.4 percent of the 203 patients maintained on doses greater than 45 mg/day. And, for those patients maintained on doses of 75 mg/day or greater, no evidence of heroin use was found.
   
   
5. In Australia, Caplehorn and Bell (1991) showed that retention in treatment increased by a factor of about two across each of three stratified levels of dose: <60 mg/day, 60-79 mg/day, and 80+ mg/day. Patients stabilized at a blockade level of 80+ mg/day or greater have longer periods of treatment than patients maintained on lower doses. Variables usually associated with good treatment outcomes, such as employment, educational level and degree of criminality, appeared to have less of an impact on retention than the patient's dose of methadone.
   
   
6. In a nationwide study of 172 randomly selected methadone maintenance treatment programs, 72 percent responded representing approximately 20 percent of the programs in operation. D'Aunno and Vaughn (1992) found that about half of the programs encouraged patients to withdraw from methadone within six months after admission to treatment. Sixty-eight percent of the programs set an upper limit for methadone doses at 50 mg/day.
   
   In addiction to the above findings, D'Aunno and Vaughn (1992) determined that patients maintained on the higher doses remained in treatment longer. Positive treatment outcomes were more likely in programs with flexible take-home privileges and in programs that included patients in decisions related to dosage. They recommended monitoring and, in certain cases, changing the treatment practices of programs prescribing inadequate doses with minimal patient participation in decision making. Programs treating high percentages of African-American patients, younger populations and the unemployed appeared to have set lower dose limits for patients and on the average administered lower doses of methadone. Many of these programs may have encouraged patients to withdraw from methadone and leave treatment prematurely, and had less patient participation in decision making.
   
   
7. The United States General Accounting Office (GAO) reviewed 24 methadone programs in eight states and concluded that "60 milligrams of methadone is the lowest effective dose to stop heroin use and low dose maintenance (20 to 40 mg) is inappropriate" (GAO, 1990). The GAO report indicated that in an effective program no more than 20 percent of the patients should have positive urine screenings for heroin at any given time.
   
   
8. Results of a recent reader survey undertaken by the Addiction Treatment Forum (1993) reported a mean dose of 56.58 mg/day and a median dose of 60 mg/day for the 203 programs that responded. While this dose is above the average dose reported by D'Annuno and Vaughn (45 mg/day), about 50 percent of the patients included in this survey are below the optimum dose range of 80 to 100 mg/day as recommended by NIDA (Schuster, 1989), the GAO (1990) and the studies reviewed in this article.

After oral ingestion, methadone goes directly to the intestinal tract and about 98 percent of the drug is absorbed and bound mostly in the liver and the remainder is stored in nonspecific tissues throughout the body (Borg, Ho & Kreek, 1992; Dole, 1988; Kreek, 1988; Kreek, 1986). This bound methadone acts as a reservoir and is gradually released back into the blood stream. With an adequate daily dose, the blood level of methadone is steadily maintained and continuously buffered by the reserve in the tissues and liver over a 24- to 36-hour period.

The daily dose of methadone must be adequate and concentrated in the blood between 150 to 600 ng/ml, (1) which is equivalent in the average patient to about 80 to 100 mg/day. A smooth flat curve of circulating methadone is achieved with a peak level occurring between two and six hours after ingestion. Since the patient is tolerant to the narcotic effects of methadone, the peak level of concentration does not produce narcosis. The concentration of methadone in the blood is therefore stabilized by its reversible binding to nonspecific tissues and the liver (Dole, 1988; Kreek, 1988; Kreek, 1986). Most importantly, with an adequate, steady and stable concentration of methadone circulating in the blood, the m receptor sites within the brain and central nervous system are continuously occupied by methadone (Dole, 1988).

Because of differences in metabolism and body weight, methadone dose must be determined individually to maintain appropriate methadone blood levels throughout the 24-hour period. If a patient metabolizes methadone at a fast rate, the dose should be increased until a steady state is achieved. A few patients may need 100 to 120 mg/day or greater. On the other side of the spectrum, those patients with slow metabolic rates may be able to adjust on doses lower than 60 mg/day. Patients who do not receive an adequate dose of methadone will experience drug hunger and symptoms of the abstinence syndrome within a 24-hour period (Kreek, 1988; Kreek, 1986).

Physicians in Europe and the United States have been determining methadone dose by measuring plasma levels (Blix, 1990; Lorimer, Schmid, Grunberger, Jagsch, Linzmayer & Presslich, 1991; Tennant, 1987). Methadone plasma levels were measured at the peak hours after dosing, two, four and 24 hours, and by then raising the methadone dose until a stable plasma level is achieved throughout the 24-hour period. Methadone plasma levels should never be used to set an upper dosing limit and it is important that dose be determined individually through consultation with the patient who should feel comfortable and be able to function. The refinement of this technology in methadone treatment is important so that dose levels be given a scientific basis.

At present, 150 ng/ml is generally accepted as the lowest plasma level of methadone that will maintain the 24-hour steady-state effect (Borg, Ho & Kreek, 1992). The optimum dose is the level at which there is adequate methadone to provide constant availability to the opiate receptors. The optimum 24-hour mean plasma level may be more in the 400 ng/ml range. Loimer and colleagues (1991) suggest that "methadone plasma concentrations of 400 ng/ml are necessary to suppress any further opiate action and to provide stabilized maintenance. Therefore, to achieve relief of narcotic hunger and to ensure a narcotic blockade, a range of 80 to 120 mgs/day would, at least at the beginning of treatment, be reasonable for patients entering treatment.

On average a dose range of 80 to 120 mgs/day will relieve narcotic hunger and ensure a high enough level of tolerance for narcotic blockade. However, there is a small group of patients, perhaps 5 percent, who are fast metabolizers (Tennant, 1987). These patients may need doses in excess of 120 mgs/day to achieve a steady plasma level of methadone for 24-hours. Any drug that stimulates the liver's microsomal enzyme-oxidizing system may accelerate the metabolism of methadone and produce withdrawal symptoms (Kreek, 1987). Again, the proper procedure is to increase the dose to over 100 mg/day to treat patients receiving medications that stimulate the liver's microsomal enzyme-oxidizing system. Another strategy is to increase the dosage and administer the medication in split doses, half in the morning and half in the evening. Medication known to produce these effects are rifampin for drug-restraint TB and dilantin and carbamazepine for patients with epileptic seizures (Kreek, Garfield, Gutjahr et al, 1976). Excessive use of barbiturates, other sedative hypnotic drugs and alcohol may also produce withdrawal symptoms (Tong, Pond, Kreek et al, 1981). A recent investigation on the effects of cocaine/crack on the endogenous opioid receptor-ligand system has reported that crack/cocaine increases the number of opiate receptors in the brain (Unterwald, Horne-King & Kreek, 1992). While the impact of this effect on methadone dose has not been studied, taken with other evidence that the majority of cocaine/crack using methadone patients request dose increases, it is likely that the use of cocaine/crack can disrupt the ratio of methadone binding to receptors. The increase in the number of opiate receptors may necessitate an increase in methadone in order to maintain an adequate dose.

The dose of methadone, as in any other medication, is critical to achieving a therapeutic effect. The most effective method to determine the proper and adequate dose is through measurement of methadone blood levels, which should be between 150 to 600 ng/ml and is equivalent in the average patient to about 80 to 100 mgs/day. Patients not receiving an adequate dose do not obtain the benefits of the medication, including the blocking of drug craving and hunger, the blocking of any euphoric effects should heroin be tried, and a degree of protection from respiratory depression and opioid overdose should illicit heroin be attempted. For the opiate-dependent person methadone when prescribed adequately acts as a stabilizer of a dysfunctional physiology by maintaining adequate opiate receptor occupation over a 24- to 36-hour period.

Many states, regions and/or programs limit methadone dose by not prescribing any dose above 50 mg/day despite the evidence to the contrary that doses below 50 mg/day are not effective for most patients (Cooper, 1992; D'Annuno & Vaughn, 1992; GAO, 1990). Medical decisions about dose should be based on sound scientific knowledge and clinical evaluation, rather than on public biases or politics (Ball & Ross, 1991). It cannot be over emphasized that using methadone as a tool to control social behavior is destructive to patients self-esteem and their therapeutic relationship to the program (Dole, 1988), and that decisions regarding methadone dosage not based on sound medical principles in fact, prevent the effective treatment of narcotic addiction (Cooper, 1992; Schuster, 1989). Kreek (1988 & 1986; Borg, Ho & Kreek, 1992) states that whatever method is used to determine methadone dosage, either through blood levels or observation of the patient, "methadone dosage should never be used for social rewards or punishment" as dependence has been medically induced.

Since dose is clinically determined, patients take home medication should not be linked to the amount of methadone prescribed, i.e. patients on lower doses allowed take home medication while those on higher doses receive no take home privilege at all. This encourages patients to prematurely lower their methadone dose resulting in the possible return to drug use and risk of HIV infection. In addition, methadone should never be used as a behavioral tool to manipulate the patient to comply with program policy (Brecher, 1972). Methadone medication should not be withheld or delayed, except for medical reasons. Program policies that encourage manipulation of patient behavior and control in order to comply are destructive to the patients trust in the program. Knowledge of dose should never be withheld. Methadone patients have the right to know their dose as do other medical patients (D'Annuno & Vaughn, 1992). The harm of withholding the amount of methadone prescribed is damaging to patients' feelings of self-worth, trust in the program, their subsequent adjustment and retention in treatment (D'Annuno & Vaughn, 1992).

II Methadone Maintenance Treatment Continued