What is Methadone?
Methadone is a synthetic opioid that was approved by the FDA in 1947 for both analgesic (pain relieving) and antitussive (cough suppression) uses. Its effectiveness in treating opiate addiction became apparent, especially in the mid 1960-s, and the FDA formally approved it for that purpose in 1972.
Methadone is a weak opioid that doesn’t produce the euphoric high that is experienced with more powerful versions like heroin and OxyContin (oxycodone) when taken as prescribed but still reduces the symptoms of withdrawal and cravings. It does this by “tricking” the brain into thinking that it is still receiving the abused opioid drug, and thereby stops the individual’s intense cravings for their previous opioid of choice.
It is one of three current FDA-approved drugs for opioid addiction treatment along with buprenorphine and naltrexone. It is highly recommended that these therapies are taken as part of a medication-assisted treatment program (MAT) that includes counseling and social support.
The chemical form of the drug was developed by German scientists during the 1930’s as part of an effort to find an opioid analgesic alternative wasn’t as addictive as morphine. Then, as world war II raged and there was a shortage of morphine, German scientists picked up the earlier research and began synthesizing it for use. After the war ended, the United States had obtained the rights to the drug from war requisitions, named the generic form methadone, and introduced it stateside States in 1947 under the brand name Dolophine.
Street Names: Amidone, Chocolate Chip Cookies, Fizzies, Maria, Pastora, Salvia, Street Methadone, and Wafer
Branded versions include Dolophine and Methadose.
Originally approved in 1947 for pain management, methadone was then primarily used in the 1970’s to 1990’s as a detoxification therapy (or rather medically supervised withdrawal) as well as a maintenance therapy for opioid addiction. In the 2000’s, methadone started to be prescribed more and more again as an analgesic for moderate to severe pain. In 2006, the FDA issued a PHA (public health advisory) warning that the drug’s use for pain management could produce serious consequences including life-threatening cardiac arrhythmias and death. Still, the number of methadone prescriptions dispensed in 2013 was 3.9 million according to IMS/IQVIA. When used as an opioid analgesic, methadone can be dispensed by any licensed pharmacy.
According to the CDC’s National Vital Health Statistics reports, there were over 4,500 methadone deaths in 2011 ranking it the fourth highest drug in overdose fatalities. In 2016, it caused close to 3,500 overdose deaths or 5% of the total drug fatalities, ranking eighth on the list. In comparison, morphine caused over 5,000 deaths and fentanyl accounted for over 18,000 fatalities or close to 30% of total drug deaths in 2016.
It is a schedule II substance under the DEA’s Controlled Substance Act along with other entities like morphine, hydrocodone and oxycodone.
Methadone Treatment and Maintenance
As mentioned earlier, the drug is used in two ways to treat opioid addiction. The first is as a medically supervised withdrawal or detoxification therapy that uses the drug’s long-acting opiate properties to subdue withdrawal symptoms when stopping opioid use. The second is as a maintenance treatment that a patient is placed on longer term to manage cravings and the desire to abuse while allowing the individual to re-integrate into society and live a normal life. NIDA recommends methadone maintenance therapy (MMT) for at least 12 months and patients can stay on it for years.
The use of methadone to treat opioid addiction has long been controversial. Yet, over the years, many studies have established its effectiveness and positive outcomes in this regard. These include:
- Reduced mortality
- Reduced addiction and abuse
- Reduced criminal activity such as thieving and prostitution
- Reduced transmission of bloodborne viruses such as HIV and Hepatitis
- Improved physical and psychological wellbeing
- Improved social re-integration
It has been documented that methadone maintenance treatment reduces the risk of death by over 75%.
Reasons Why Methadone is Controversial
Issue #1: The addiction is only replaced
This is true in that methadone can be viewed as simply being a legal substitute for heroin or tramadol or other such substances. However, by being a weak substitute, it prevents the euphoric high, reduces cravings, and prevents debilitating physical withdrawal symptoms.
Issue #2: Individuals with addictions keep on using
Opponents ask, what is the use of an addiction treatment if the individual does not actually quit taking a substance at some point. As a “maintenance therapy” patients can stay on methadone for months and years. Would we ask a similar question about diabetes maintenance drugs or statins for heart disease? As the science of addiction has educated that it is a chronic brain disease and not a moral failing, the National Institute of Drug Abuse and other organizations are trying to increase education and awareness to continue destigmatizing addiction to more and more have it be treated as it should be, i.e., as a chronic disease similar to diabetes for example.
Issue #3: Cost of treatment
Critics raise the concern of how much treatment costs. According to NIDA, one year of methadone maintenance treatment costs on average about $4,700 for an individual. In comparison, one year of imprisonment costs $24,000. NIDA points out that several conservative estimates indicate that each dollar invested in addiction treatment yields a return of $4 to $7 by reducing crime and its related criminal justice system costs. With healthcare costs factored in, the total return can be up to $12 for each $1 spent.
Issue #4: It can be abused too
By providing methadone to patients on a regular basis, opponents note that ironically, this creates an opportunity for its diversion and abuse.
While this is true and abuse is witnessed, the use of methadone for addiction treatment is strictly regulated and controlled. That too is a reason often cited against it because that means access and ongoing participation is challenging to many patients. Methadone is administered through only about 1,500 Opioid Treatment Programs certified by SAMHSA under tight monitoring and controlled conditions to prevent it from slipping through the cracks and ending up being sold and used on the street.
Issue #5: Determining right dosing is not clear cut
The absorption, metabolism and elimination of the methadone varies by person depending on multiple factors and therefore each patient’s dose must be determined individually. Typically, there is a starting dose which is low which is monitored and adjusted over the first weeks and then continued to be tweaked longer term. There are many reported stories of patients feeling drowsy and suffering other side effects due to the right dose not being established. Establishing the right dose balances wooziness and other side effects with preventing physical withdrawal symptoms and cravings. This is another reason for limiting methadone administration and it is necessary for patients to bring up issues with program staff who can then take more time to check blood levels and adjust dosing as appropriate.
Methadone Clinic Overview
A patient must visit a methadone clinic to receive treatment under the supervision of a doctor. A “methadone clinic” is a SAMHSA certified Opioid Treatment Program (OTP). You can find a program near you by clicking here. Currently, there are a total of around 15,500 substance abuse treatment programs in the United States of which approximately 10% or 1,600 have certified Opioid Treatment Programs offering methadone. In 2017, 382,867 patients received methadone treatment at an OTP. This is an increase of 7% from 356,843 in 2016.
Methadone clinics or Opioid Treatment Programs provide medication-assisted treatment (MAT) for patients with an opioid use disorder. “Medication-assisted” treatment does not simply involve dispensing medication. On the contrary, medication-assisted opioid treatment must encompass a comprehensive approach that includes:
- FDA-approved medication under a supervised protocol
- Social support
- Other related health services
To this end, methadone clinics or opioid treatment programs are accredited by a SAMHSA-approved accrediting body and certified by SAMHSA.
Methadone Clinic Services
Federal law requires methadone clinics or opioid treatment programs to provide patients with a range of services apart from receiving medication. The National Survey of Substance Abuse Treatment Services conducted by SAMHSA breaks out services into 6 categories. These are:
- Asessment and pre-treatment services
This includes screening for substance abuse, a comprehensive substance abuse assessment or diagnosis, screening for mental health disorders, outreach to persons in community who may need treatment, screening for tobacco use, comprehensive mental health assessment or diagnosis, and interim services for clients when immediate admission is not possible.
Testing services cover, drug and alcohol urine screening, breathanalyzer or other blood alcohol testing, tuberculosis screening, HIV testing, screening for hepatitis B and C, and testing for STDs (sexually transmitted diseases).
Apart from providing the three FDA-approved drugs for MAT (methadone, buprenorphine, naltrexone), some facilities select to provide medications for psychiatric disorders, nicotine replacement, and others.
- Transitional services
Two services are covered here, discharge planning and aftercare/continuing care.
- Ancillary services
These include but are not limited to substance abuse education, social skills development, mental health services, mentoring/peer support, assistance in locating housing for clients, self-help groups, transportation assistance to treatment, domestic violence services, child care for clients’ children.
- Other services
Mainly treatments for other disorders such as gambling and internet use disorder.
Counseling and Behavioral Therapies
Federal law also requires methadone clinics to offer their patients counseling services which could include different forms of behavioral therapy and counseling approaches.
Clinical/therapeutic approaches offered include but are not limited to:
- Substance abuse counseling
- Relapse prevention
- Cognitive-behavioral therapy
- Motivational interviewing
- 12-step facilitation
- Brief intervention
- Anger management
- Trauma-related counseling
Methadone Clinic Near Me
SAMHSA maintains an online directory which we have adapted for easier navigation. Click here to find the nearest SAMHSA-certified Opioid Treatment Program or Methadone Clinic in your city and state. The 1,640 programs are available in all 50 states except Wyoming. Programs are also available in the District of Columbia, Puerto Rico and US Virgin Islands.
California has the most number of Methadone Clinics (as of February, 2019) with 154 programs followed by New York state with 135. Texas, Pennsylvania and Maryland follow with 94, 91, and 88 programs each.
If after searching the directory you can’t find a program that is near enough to you, don’t give up. Talk to your family doctor or call the National Helpline at 1-800-662-HELP (4357) TTY: 1-800-487-4889 to look at alternative options such as a buprenorphine clinic or provider near you.
What is SAMHSA’s National Helpline?
SAMHSA’s National Helpline, 1-800-662-HELP (4357), (also known as the Treatment Referral Routing Service) or TTY: 1-800-487-4889 is a confidential, free, 24-hour-a-day, 365-day-a-year, information service, in English and Spanish, for individuals and family members facing mental and/or substance use disorders. This service provides referrals to local treatment facilities, support groups, and community-based organizations. Callers can also order free publications and other information.
What to Expect at a Methadone Clinic
The clinic will typically conduct a short pre-screen on the phone with the patient and ask them about their history and opioid use. It is useful for the patient to have their Medicaid number or other health insurance information and also be ready to provide their social security number and date of birth if asked. Depending on the phone screen, the clinic may recommend scheduling an appointment or may provide a referral to another program as appropriate.
If proceeding, the clinic will then schedule the patient to come in for a first appointment which is mostly an intake visit. At this visit, the patient is seen by the doctor and counselor. It’s a good idea to set aside about two hours for this first visit. The doctor will get a detailed history and do an assessment and the patient may be asked to do a urine test onsite. If blood and other tests are needed, those are referred out to a LabCorp or other testing site.
The goal is to start methadone treatment on the first day but will depend on the doctor’s assessment and recommendations.
Methadone is available as a liquid syrup, pill, or wafer to be taken once a day. The drug provides pain relief for about four to eight hours.
The patient will have to go to the clinic every day to get their daily dose. Clinics typically recommend budgeting about 45 minutes but often able to get patients in and out faster in 20 to 30 minutes. However, this will vary with a specific program which might be busier and see a larger number of patients and should be discussed with staff. Clinics usually open early in the morning to facilitate patients being able to get their daily dose expeditiously so that they could then go on to work or other activities. If the clinic is closed on Sundays, the patient will be given an extra dose to take home on Saturday.
Weekly or periodic individual counseling sessions will be scheduled, as well as group meetings.
Patients will have to visit the clinic daily to receive their dose usually for at least the first 90 days. After that, based on their progress and other factors, patients could be allowed to take methadone at home and not have to visit the clinic daily.
The length of time in methadone treatment varies from person to person. According to the NIDA, the length of treatment should be a minimum of 12 months. Some patients however may require treatment for another year or several more years, even longer.
A patient should only stop treatment under supervision of a doctor at the appropriate time. If stopped suddenly, withdrawal symptoms could cause great discomfort and therefore the doctor and medical staff at the clinic will map out a plan to gradually taper the patient off medication.
The following is excerpted from the drug’s label accessed here at https://www.accessdata.fda.gov/drugsatfda_docs/label/2018/006134s046s048lbl.pdf#page=33 on 2/19.
Medically Supervised Withdrawal after a Period of Maintenance Treatment for Opioid Addiction
There is considerable variability in the appropriate rate of methadone taper in patients choosing medically supervised withdrawal from methadone treatment. Dose reductions should generally be less than 10% of the established tolerance or maintenance dose, and 10 to 14-day intervals should elapse between dose reductions. Apprise patients of the high risk of relapse to illicit drug use associated with discontinuation of methadone maintenance treatment.
If for some reason, it is decided that a patient should remain on methadone maintenance for a longer time, that is perfectly fine. Many patients go on to live happy and productive lives while being on methadone for years.
Methadone Side Effects
Possible side effects include:
- Abdominal pain.
Talk to the staff at the clinic or your family doctor if you have any of these symptoms and they are severe.
Get emergency help if you experience any of the following serious side effects. Stop taking methadone and contact your family doctor, the clinic or go to an emergency room if you:
- Experience difficulty breathing or have shallow breathing
- Feel lightheaded or faint
- Notice swelling of the face, lips, tongue, or throat
- Feel chest pain
- Experience a fast or pounding heartbeat
- Experience hallucinations or confusion
- Have a high body temperature
- Have trouble walking or experience stiff muscles
Methadone maintenance doses are optimized to prevent a patient from experiencing that euphoric rush or “high” as well as to prevent opioid withdrawal symptoms and reduce or eliminate cravings. However, if unusually large amounts of the drug is consumed, it is possible for an individual to experience sensations of euphoria and if it is injected or snorted its effects were shown to be no different from morphine or heroin in the following study, Comparison of intravenously administered methadone, morphine and heroin.
Methadone Addiction and Safety
Methadone can be addictive, so it must be used exactly as prescribed. This is particularly important for patients who are allowed to take methadone at home and aren’t required to take medication under supervision at an OTP. Methadone medication is specifically tailored for the individual patient (as doses are often adjusted and readjusted) and is never to be shared with or given to others. Patients should share their complete health history with health providers to ensure the safe use of the medication.
Other medications may interact with methadone and cause heart conditions. Even after the effects of methadone wear off, the medication’s active ingredients remain in the body for much longer. Taking more methadone can cause an unintentional overdose.
The following tips can help achieve the best treatment results:
Never use more than the amount prescribed, and always take at the times prescribed. If a dose is missed, or if it feels like it’s not working, do not take an extra dose of methadone.
Do not consume alcohol while taking methadone.
Be careful driving or operating machinery on methadone.
Call 911 if too much methadone is taken or if an overdose is suspected.
Take steps to prevent children from accidentally taking methadone.
Store methadone at room temperature and away from light.
Dispose of unused methadone by flushing it down the toilet.
How Long Does Methadone Stay in Your System
Methadone has a relatively long half-life compared to other opioids because it accumulates in the body’s tissues and liver. The half-life varies between 8-59 hours depending on other factors in a person’s body.
Methadone Withdrawal Symptoms
Common withdrawal symptoms if methadone is abruptly stopped could include:
Other withdrawal symptoms that may develop, include:
- Joint pain
- Abdominal cramps
- Increased blood pressure, respiratory rate, or heart rate