Wednesday, May 27, 2015

Maintaining Consumer Choice in Treating Substance Use Disorder:

Benefits and Risks of Methadone Maintenance & Abstinence-Based Residential Treatments


It is crucial for consumers of treatment services as well as policy makers to have reliable and accurate information regarding various treatments for substance use disorders –particularly when opiate addiction and overdose is currently our state’s top healthcare AND budgetary crisis. 

The two most prominent methods for treating SUD –Methadone-Maintenance Treatment (MMT) and Abstinence-Based Residential Treatment (ABRT) have prevailed since the 1960s, and both are supported by a wealth of valid credible research.  Searches on this topic refer to literally hundreds of empirically based studies citing the effectiveness of both MMT and long-term ABRT (Reif, et al, 2014; Brunette, 2004; Stein; United Nations –New York, 2002).

RECENT POLICY IMPLICATIONS:
          1)  Access to Recovery (ATR) funding only covers halfway houses and sober living programs that support Methadone Maintenance, but not Abstinence-Based Residential Treatment;
          2)  Recent changes to Maryland Medicaid caused by integration, only allows compensation for MMT, but not ABRT –putting some residential detox facilities (the initial level of care in ABRT) at risk of closing.

WHAT IS METHADONE MAINTENANCE TREATMENT (MMT)?
Methadone Maintenance Treatment substitutes methadone –a synthetic long-acting opiate, for other shorter-acting opiates (such as heroin).  It is administered over a prolonged period of time (possibly indefinitely), as a ‘harm reduction’ strategy for an individual addicted to opioids.  It works by maintaining the level of drugs in an individual’s system, thereby avoiding the uncomfortable withdrawal symptoms associated with abstinence.  Because methadone is long acting –it need be administered only once a day to suppress withdrawal symptoms, thereby making it an ideal drug for managing an individual’s opioid dependence in a much more stable and predictable manner than shorter acting opioids, which wear off quickly and oftentimes must be used several times each day to stave off withdrawal symptoms. 

WHAT IS ABSTINENCE-BASED RESIDENTIAL TREATMENT (ABRT)?
Abstinence-Based Residential Treatment typically includes the use of Buprenorphine administered in ever lowered doses over a relatively short and finite period of time to lessen the most severe withdrawal symptoms, followed by abstinence from all drugs in a safe, controlled and supportive environment –thereby breaking the neurological brain-based dependence on the drug. Symptoms associated with long-term withdrawal, such as “cravings”, are neutralized through small group support, counseling, and holistic therapies (exercise, saunas, meditation, etc.)  Thus, the emotional toll of withdrawal can be sufficiently limited and physical withdrawal symptoms can be adequately managed.  Numerous studies show that the amount of time spent in residential treatment is proportional to the chances of actually achieving long-term recovery from opiate dependence.

RISKS & BENEFITS:  Both MMT and ABRT reduce mortality, intravenous drug-related behaviors (theft, burglary, prostitution, etc.), transmission of HIV, and criminal activity.  However, consumers often want to weigh other benefits and risks when choosing which path to recovery is right for them.  DHMH and county health departments must preserve consumer choice by maintaining funding streams for both options and ensure equal accessibility.  Below is a table of the benefits and risks associated with both:

METHADONE MAINTENANCE
ABSTINENCE-BASED RESIDENTIAL
BENEFITS
·         MMT allows patients to safely manage their disorder and to choose the most suitable time (if ever) for weaning off opiates

·         Alleviates opioid withdrawal symptoms and opioid “cravings” associated with abstinence from opioids

·         Reduces the euphoric effects of other opiates

·         About 28% – 33% of MMT patients do not use other illicit drugs while in treatment (Flynn, et al. 2003; Cohen, et al., 2005)

·         ABRT allows patients to eliminate their dependence on addictive drugs in a highly structured and supportive environment

·         About 67% of ABRT patients do not use other illicit drugs while in treatment (Cohen, et al., 2005)

·         Suicidal ideation is reduced by 41% – 47%, but not among MMT patients (Hubbard, et al. 1997)

·         Increases in full-time employment correlate with patients remaining in ABRT for 6 months, but not among MMT patients (Hubbard, et al. 1997)

·         ABRT patients’ cognitive brain functioning may eventually be restored (Davis, et al., 2002; Mintzer, et al., 2004)

RISKS
·         Highest death rate of any opiate –2X as many as OxyContin (CDC, 2012)

·         Dangerous interactions with other drugs (such as antianxiety medications (CDC, 2012)

·         Causes major disturbances of cardiac rhythm (CDC, 2012)

·         MMT patients are at a higher risk of death from drug overdose even when under the care of a methadone treatment provider (Maxwell, et al., 2005; Best, et al, 2009; SAHMSA, 2010)

·         Suicidal ideation is particularly high among MMT patients (Hubbard, et al. 1997; Best, et al, 2009)

·         MMT has been linked to impaired cognitive function in a 2013 systematic review of 35 published scientific studies (Wang, et al., 2013)

·         MMT has been linked to neuropsychological deficits (Davis, et al., 2002; Mintzer, et al., 2004)

·         MMT has been linked to slower cognitive processing speeds, lower visual-spatial attention spans and lower cognitive flexibility, as well as less accuracy on working memory and analogical reasoning than ABRT (Verdejo, et al., 2005)

·         MMT has been linked to lower scores on emotion perception and social inference than ABRT (McDonald, et al., 2012)

·         MMT has been linked to suppressed testosterone levels associated with erectile dysfunction, fatigue, and mood disturbances (McMaster University, 2014)
·         Short stays (30 days or less) have about a 5% success rate.  Programs that discharge clients after 30 days give the patient the false impression that they are healed, when in fact, only longer stays (at least 3 to 6 months) correlate with higher successful outcomes than outpatient treatment (United Nations –New York, 2002; Hubbard, et al. 2003; Tiet, et al., 2007)

·         ABRT patients are at a high risk of overdose if they resume opiate use at the same dosage level as prior to treatment, since their tolerance is much lower. 

Ms. Lowe holds a Bachelor of Science degree in Sociology from Towson University and a Master of Applied Anthropology degree from the University of Maryland.  She was a former freelance editor for a psychiatric research journal and is well-versed in analyzing research studies.  

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