Methadone Maintenance Treatment: How Methadone Treats Opioid Addiction

Methadone maintenance treatment (MMT) is the current standard of care for treating individuals with opioid use disorder.¹ This treatment requires you to receive methadone in a highly structured environment and aims to reduce or eliminate your opioid use completely.¹ For those who misuse opioids and want to quit, MMT is one of the most effective medication-assisted treatments (MATs) available. Methadone maintenance can reduce overdosing, arrests, and the chances of contracting blood-borne viruses like HCV and HIV.^{2, 3}

In this article:

• Methadone Maintenance and its Effects on Opioid Addiction
• Signs You May Need Methadone Maintenance Treatment
• How Methadone Interacts with Other Drugs
• Risks Associated with Methadone Maintenance Treatment
• How Methadone Maintenance Treatment is Administered

Methadone Maintenance and its Effects on Opioid Addiction

Chronic opioid use causes chemical and structural changes in your brain, and these changes may last long after you stop using opioids. Opioid misuse alters your brain’s reward circuit so much that you may experience persistent desire (i.e., cravings) even without withdrawal symptoms. This can lead to compulsive substance-seeking behavior (i.e., addiction). As such, opioid addiction may be difficult to overcome on your own, without professional treatment, such as methadone maintenance treatment.

Methadone is an opioid agonist medication that block the effects of opioids and stabilize the nervous system.³ Maintenance treatment entails that you will remain on methadone intentionally for long periods.¹ A specialized addiction physician provides detailed care that includes urine analysis tests, general medical care, and counseling.¹

Continuous methadone maintenance treatment over years or decades with gradual reduction in medication improves your mental and social wellbeing. It also reduces the rate of life-threatening events due to opioid misuse. Pharmacological maintenance treatment is associated with fewer consequences of opioid use (i.e., overdose, arrests, and HIV infection). It reduces withdrawal symptoms and decreases further substance use.³

Signs You May Need Methadone Maintenance Treatment

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) is used to diagnose several categories of substance use disorder. Signs of opioid use disorder as defined by the DSM-5 are as follows:⁴

1. Taking too many opioids or taking them longer than you intended
2. Being unable to control or reduce opioid use despite persistent desire to do so
3. Spending too much time getting, using, or recovering from opioids
4. Cravings (strong desire or urges) for opioids
5. Having unfulfilled duties related to work, school, or home life due to opioid use
6. Continuing opioid use despite it causing problems with friends or family
7. Reducing participation in activities you valued previously
8. Repeating opioid use at times or in places that are physically dangerous
9. Using opioids even though you know they cause psychological or physical issues
10. Building tolerance to opioids, meaning you need more to achieve the same effects, or you feel diminished effects when using the same amount
11. Experiencing opioid withdrawal symptoms when you abruptly stop or reduce your use

Within a few hours after stopping opioid use, you may experience symptoms of opioid withdrawal. These include:⁵

• Sleep problems
• Diarrhea
• Vomiting
• Cold flashes with goosebumps
• Muscle and bone pain
• Uncontrollable leg movements
• Severe cravings

Who Should Not Have Methadone Maintenance?

Some medical conditions can complicate MMT. Therefore, methadone should be prescribed with caution or not at all if you have any of the following diagnoses:^{6, 7}

• Respiratory conditions such as asthma
• Diabetes mellitus
• Hypothyroidism
• Urethral stricture
• Hypopituitarism
• Adrenocortical insufficiency
• Prostatic hypertrophy
• Lung diseases such as chronic obstructive pulmonary disease (COPD), chronic bronchitis, or emphysema
• Head injury
• Brain tumor or any condition that has increased the amount of pressure in your brain
• Malnourishment resulting from disease
• Severe liver disease (methadone may precipitate hepatic encephalopathy)
• Intolerance of methadone or ingredients in methadone formulations

Many of the above diseases contraindicate the effectiveness of methadone. Some side effects akin to methadone exacerbate preexisting conditions, such as difficulty breathing.⁷

Pregnancy and Methadone Treatment

If you are seeking or engaged in methadone maintenance and are or will soon become pregnant, discuss ongoing MMT with your primary care physician. When treating pregnant people with opioid use disorders, methadone is considered the highest standard of care among medication-assisted treatment options. However, it can be detected in cord blood, newborn urine, amniotic fluid, and it crosses the placenta. Nevertheless, newborns whose gestational parents utilize MMT while pregnant have improved fetal outcomes. Because methadone leaves the body faster when pregnant, you may need to discuss increasing your dose with your doctor.¹⁰

MMT while breastfeeding is safe as long as your infant is tolerant of the medication. Your physician will assist you in determining when you can breastfeed. When breastfeeding, methadone can be passed to the nursing child at a concentration that is about 2% to 3% of the breastfeeding parent’s dosage and appears in the milk only 4 to 5 hours after ingestion of an oral dose. Physicians may recommend that you monitor your infant after feeding to check for slowed breathing or complete sedation.¹⁰

How Methadone Interacts with Other Drugs

When deciding on MMT, be aware of the interactions that methadone has with other medications that could depress the central nervous system and cause slow breathing (e.g., other opioids, alcohol, Ativan, Xanax, Restoril, clonazepam, or Valium).

Methadone can interact with a litany of other medications, such as:^{6, 7}

• Other opioids
• Alcohol
• Benzodiazepines (clonazepam, Restoril, Xanax, Ativan, Valium)
• Antipsychotics, tricyclic antidepressants, and certain heart medications that can increase the risk of experiencing irregular heart rhythms
• Increased effects of methadone when using certain antibiotics (e.g., clarithromycin or erythromycin), certain antidepressants (e.g., Prozac or Paxil), or antifungals (e.g., Diflucan, Nizoral, Sporanox)
• Decreased effects of methadone when using naltrexone, certain antivirals (Incivek, Norvir, Fortovase, Invirase, or Kaletra), certain seizure medications (e.g., phenobarbital, Tegretol, or Dilantin), antibiotics such as Rifadin

Risks Associated with Methadone Maintenance Treatment

Public skepticism and perception associate methadone maintenance treatment with some social stigmas. One such stigma is that methadone maintenance keeps people in a lifestyle of addiction, which is unsupported by research on the subject.¹¹ However, MMT does have some legitimate concerns you should be aware of and discuss with your provider.

While MMT is a successful medical intervention for reducing life-threatening events associated with heroin use, there remain life-threatening risks during induction into treatment.^{11, 13} Depression also coincides with methadone maintenance among opioid use disorder patients.¹² Finally, due to growing availability, methadone overdosing has become a significant problem.¹³

Methadone Overdose: Signs and Symptoms

Signs and symptoms of methadone overdose include:⁶

• Sedation
• Pinpoint pupils
• Respiratory depression (slow breathing)
• Low blood pressure
• Nausea
• Vomiting
• Dizziness
• Slurred speech
• Snoring
• Slow pulse
• Shallow breathing
• Frothing at the mouth
• Unconscious and unable to be roused

How Methadone Maintenance Treatment is Administered

Methadone is dispensed from designated methadone clinics that are staffed and open to clients seven days a week.⁶ To ensure accurate dosing, these clinics are equipped with dispensing pumps or measuring cylinders; to ensure safety, they are equipped with resuscitation equipment and basic first aid.⁶ Methadone is stored in a secure area on site that is not obvious to the clientele.⁶ Once you receive your prescribed dose, you will be asked to sit in a supervision room as an additional safeguard to ensure that you are not giving your methadone to others and will be checked on every 15 to 29 minutes.⁶

A systematic review revealed that the combination of psychosocial and pharmacological detoxification interventions effectively improved rates of treatment completion, increased rates of levels of treatment attendance, reduced opioid use, and facilitated longer abstinence.⁸ It also was found that no one psychosocial approach was superior in treating opioid use disorder.⁸

Where Methadone Treatment Is Monitored

How methadone is monitored in the United States is similar to how it is monitored in Canada. In Ontario, Canada, those in need of MMT receive treatment at a specialized clinic (methadone clinics in the United States) and are monitored daily by a nurse or pharmacist who observes their medication intake.¹ The American model is more restrictive than the Canadian model insomuch that directly observed therapy only permits methadone dosing to occur at designated, regulated opioid treatment programs.¹

Induction and Dose Management

The first dose is called the induction period and is a period where the physician first introduces you to methadone. The first dose of methadone is between 10 and 30 mg, and another dose increase will not happen until the fourth day, with a maximum increase of 20 mg a week after that.⁶ If you show no signs of cravings, side effects, or withdrawals, or signs indicating that you are on too high of a dose, you will receive daily maintenance doses that will be regularly reviewed.⁶ On the other hand, if you do show any of the aforementioned signs, then your doctor will continue to make adjustments until you can answer “no” to all of the questions.⁶

Length and Challenges of Methadone Maintenance

Methadone maintenance treatment is highly beneficial and effective but can prove time-consuming. Without careful planning and flexible scheduling, MMT can be challenging to sustain.

Participants in one study referred to MMT as “liquid handcuffs.”² Many other participants echoed this stance, discussing how going to the treatment center made it difficult for them to maintain employment, and thus, financial stability. Another potential difficulty is that if you want to travel, you cannot unless the treatment facility provides you with take-home medication and gives you permission. Additionally, you cannot be late to the treatment center for your scheduled dosing. Also, since MMT is a daily commitment, it may be difficult to attend school.²

Ending Treatment and Continuing Recovery

Treatment, like assessment, is ongoing and adjusts to your needs as appropriate. Continuing your recovery after treatment can take many forms:⁹

• Continued participation in 12-step groups
• Finding or maintaining consultation with a sponsor
• Participating in groups specific to other areas that also need attention (e.g., co-dependence, parenting classes, domestic violence classes)
• Addressing lingering legal issues (e.g., requirements of probation, restitution, meetings with Child and Family Services)
• Creating and maintaining a structured routine
• Making and maintaining appropriate boundaries
• Slowly beginning to reintroduce certain support systems back into your life

Call 800-908-4823 (Who Answers?) to speak to a specialist about substance use recovery services like methadone maintenance treatment and find a methadone maintenance center near you.

References

1. Eibl, J. K., Gomes, T., Martins, D., Camacho, X., Juurlink, D. N., Mamdani, M. M., Dhalla, I. A., & Marsh, D. C. (2015). Evaluating the Effectiveness of First-Time Methadone Maintenance Therapy Across, Northern, Rural, and Urban Regions of Ontario, Canada. Journal of Addiction Medicine, 9(6), 440-446.
2. Frank, D., Mateu-Gelabert, P., Perlman, D. C., Walters, S. M., Curran, L., & Guarino, H. (2021). “It’s like ‘liquid handcuffs”: The Effects of Take-Home Dosing Policies on Methadone Maintenance Treatment (MMT) on Patients’ Lives. Harm Reduction Journal, 18(88), 1-10.
3. Tetrault, J. M., & Fiellin, D. A. (2012). Current and Potential Pharmacological Treatment Options for Maintenance Therapy in Opioid-Dependent Individuals. Drugs, 72(2), 217-228.
4. American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. American Psychiatric Association Publishing.
5. National Institute on Drug Abuse. (2021). What are Prescription Opioids?
6. National Center for Biotechnology. (2009). Methadone Maintenance Treatment.
7. Medline Plus. (2022). Methadone.
8. Dugosh, K., Abraham, A., Seymour, B., McLoyd, K., Chalk, M., & Festinger, D. (2016). A Systematic Review of the Use of Psychosocial Interventions in Conjunction With Medications for the Treatment of Opioid Addiction. Journal of Addiction Medicine, 10(2), 93-103.
9. Substance Abuse and Mental Health Services Administration (SAMHSA). (2015). Detoxification and Substance Abuse Treatment.
10. Centers for Disease Control and Prevention. (2021). Treatment for Opioid Use Disorder Before, During, and After Pregnancy.
11. Bell, J., & Zador, D. (2000). A risk-benefit analysis of methadone maintenance treatment. Drug Safety, 22(3), 179-90.
12. Peles, E., Schreiber, S., Naumovsky, Y., & Adelson, M. (2007). Depression in methadone maintenance treatment patients: Rate and risk factors. Journal of Affective Disorders, 99(1–3), 213-220.
13. Reingardienė, D., Jodžiūnienė, L., Lažauskas, R. (2009). Methadone treatment and its dangers. Medicina, 45(5), 419.