10. Methadone treatment is the single most effective treatment for opiate dependence

Top experts at the US Department of Health and Human Services, Center for Disease Control state that, “methadone maintenance treatment is the most effective treatment for opiate addiction.”

Find a link to the CDC Methadone Fact Sheet here:

Methadone treatment is an evidence-based treatment.  It is not based on a theory or a philosophy.  It is based on medical research.

Scientists and other experts have extensively studied methadone treatment for decades.  Methadone has a long and well documented track record of success.

Let’s consider the range of available treatments for opiate dependence, and see how methadone stacks up.

No treatment

Many people who use heroin or other opiates are able to stop using and build a stable recovery without any treatment at all.  On the other end of the spectrum, many others have tried their best dozens of times to stop using without success, even with treatment.

Most of the time, the difference isn’t about how hard they tried, how much they wanted it, or anything to do with willpower.

Instead, it’s about how long the person has used, how much they have used, whether they have a genetic predisposition for addiction, whether opiate use has changed their brain chemistry, or whether they also have mental health challenges.  It’s fair to say that those who have tried repeatedly to stop using without success have a complex addiction.

Methadone treatment is not appropriate for people who are able to stop using on their own without any treatment.  But methadone has helped many of those on the other end of the spectrum who are living with a complex addiction succeed in recovery when nothing else worked.

Self-help groups

Self-help groups, including 12-step groups like AA and NA, are a useful recovery support tool for many people.  However, self-help group participation alone is usually not enough to result in long term recovery for people with complex addiction to opiates.

Methadone treatment is not appropriate for people who are able to sustain recovery through self-help groups alone.  But methadone is appropriate for people who are not able to sustain recovery through self-help groups alone.

Methadone treatment is much more successful than self-help groups in creating the conditions for long term recovery among people with complex addiction to opiates.  Participation in a self-help group without more is unlikely to be an effective recovery plan for a person with a complex addiction to opiates.

Some people choose to use self-help groups as a recovery support while participating in methadone treatment.

Detox

Detoxification or detox is simply the process of stopping opiate use and allowing the body to readjust to functioning without taking opiates.

Detox can be done at home, through an outpatient detox program or through a residential detox program.  Detox can be done quickly by a sudden termination of opiate use, or more slowly via a gradual reduction in doses over a period of days, weeks or months.  Detox can be done “cold turkey” or with a variety of supports including use of medications like clonadine, methadone or buprenorphine.  It can even be done under anesthesia such as in so-called “rapid detox” programs (these so-called rapid detox programs are potentially fatal and are not recommended).

Detox is a necessary first step for those who are seeking recovery for those who are not participating in medication-assisted treatment with methadone or buprenorphine (Suboxone/Subutex).  But detox alone is not effective in producing a long term recovery from opiate dependence, especially among people with complex addiction.  I would compare it to one-time fasting as a way to create long term weight loss.

It’s worth noting that the need to detox is a major barrier to recovery for many people.  It’s difficult for many people to voluntarily sign up for that kind of agony -especially since many have already been through detox multiple times and already realize that detox alone has not been enough for them to achieve lasting recovery in the past.

One of the benefits of methadone treatment is that detox is not required  because methadone prevents withdrawals.  Methadone also limits the cravings that follow detoxification.  These are two of the reasons that methadone treatment program is much more likely to result in long term recovery than a detox program.

Another reason is that many people have experienced changes to their brain chemistry because of opiate use.  For these people, detox results in a brain that is deprived of what we all need to feel normal or happy.  In contrast, methadone helps the person in recovery maintain a healthy chemical balance in the brain and feel normal.

Outpatient counseling

Outpatient counseling is sufficient treatment to result in successful recovery from opiate dependence for some people.  Methadone treatment is not appropriate for people who are able to stop using with outpatient counseling alone.   But for people with a complex addiction to opiates, the combination of medication plus counseling is very powerful.  This is why most methadone maintenance programs include outpatient counseling as part of the treatment mix.

Outpatient counseling is very helpful in that it provides an opportunity for the counselor and person living with addiction to assess the addiction, address co-occurring or underlying conditions such as mental health conditions, address barriers to recovery, and create a realistic long-term recovery plan.  Outpatient counseling has the potential to be highly individualized and flexible.  And outpatient counseling can provide treatment and support over an extended period of time.

Done right, the counselor and counseling client form a therapeutic alliance that helps keep the client engaged in treatment, and helps the client build and sustain motivation for positive change.  This requires significant skill on the part of the counselor, and a good match between counselor and client.

Unfortunately, many counselors lack the skill to effectively engage clients, retain clients, build and sustain motivation, or support action toward positive change.

This is why the most common number of treatment sessions between and outpatient counselor and a person living with opiate dependence is zero (meaning the outpatient counseling program is not successful in attracting the person into treatment).  And the second most common number of treatment sessions is one (meaning the person was willing to try meeting with the counselor, but the counselor was not successful at engaging the client).  This is too bad, because these are opportunities lost.

Combining outpatient counseling with methadone maintenance significantly improves engagement, retention and treatment outcomes over counseling alone for people with complex addiction to opiates.  The addition of methadone maintenance improves the safety of the treatment both because people stay in treatment longer and because methadone limits relapse risk.  And the addition of methadone improves recovery sustainability because people tend to be more successful at achieving abstinence from harmful drugs and stay in treatment longer.

Outpatient counseling is less intrusive upon the life of a person living with opiate dependence than residential treatment.  In other words, there are fewer barriers to accessing outpatient counseling for most people than for accessing residential treatment.  For example, people can continue working and caring for their children when in outpatient counseling and this is often impossible if the person is in residential treatment.  This is an important benefit in terms of attracting and retaining clients in treatment.

Outpatient counseling is most effective in addressing complex addiction to opiates when it is combined with medication-assisted treatment with methadone.  Outpatient counseling plus medication is a realistic core treatment for a person with complex opiate addiction, and is often a solid foundation for a safe and sustainable long term recovery.

Residential Treatment

Residential treatment provides a useful interrupt for those experiencing chaotic drug use.  Residential treatment provides a safe place for a person to stay while they seek to stabilize.

Many people benefit from getting out of their usual environment for a while as they seek to initiate abstinence from harmful drugs.  Part of this is separating from harmful people and places, and the temptations they face in the community where drugs are plentiful and readily available.

Residential treatment can be a good place to detox from harmful drugs.  It can be a good place to begin taking medications that support recovery such as buprenorphine (Suboxone/Subutex) or methadone.  And it can be a time and a place for people to learn about treatment and recovery.

The combination of long term residential treatment plus methadone (or buprenorphine) is a very powerful combination that can be highly effective for people with a complex addiction to opiates -even those who have not been successful with outpatient methadone treatment or residential treatment alone.  Unfortunately, there are not many programs that combine these two elements.

Once a person leaves residential treatment, the person is at an increased risk for both relapse and fatal drug overdose.  Having a solid after care plan in place is critical because recovery success rates for people with complex addiction to opiates after short term residential treatment  alone is low.  Success after long-term residential treatment (meaning over 90 days and the longer the better) is better, but relapse is still common.

Success is improved if residential treatment was combined with medication-assisted treatment with methadone or buprenorphine.  But many residential treatment programs lack the capacity to provide medication-assisted treatment.  Many are not supportive of medication-assisted treatment on “philosophical” grounds, and therefore ignore the science of recovery to the detriment of their clients.

Many residential treatment programs have low treatment retention (lots of people leave treatment early or are discharged from treatment early).  Part of the reason is that residential treatment is very disruptive to people’s lives.  Many people are uncomfortable in the residential environment and miss the comforts of home.  Added to this is the fact that people who are newly in treatment are often detoxing, have little momentum in their recovery, and are experiencing powerful drug cravings.  Many programs lack skilled and professional staff, make no attempt to provide good customer service, and consider a confrontational approach to be somehow therapeutic.

Recovery success rates with short term residential treatment alone for people with complex opiate addiction are not good.  Short-term residential treatment is best viewed as a tool to be used for the benefits it does provide in the context of a broader recovery plan.

Success rates for long term residential treatment are better than for short term residential treatment, but not better than success rates for outpatient methadone maintenance treatment.

Sober houses/Halfway houses

Stable housing is an important part of stable recovery.  Sober houses or other halfway houses are a useful recovery support tool.  However, taking up residence in a sober house alone is usually not enough to result in long term recovery for people with complex addiction to opiates.

Success is more likely if the sober house is part of a larger plan that includes adequate treatment and other supports.

Most sober houses or halfway houses are primarily housing.  They usually offer no formal treatment.

The best include a core group of residents who are stable and have been in recovery for quite a while.

Those with a lot of turnover often are not safe places to live.  Most of the residents will be in early recovery, and some will not be in recovery at all (either they have no place else to go, or they are mandated to live in sober housing by the criminal justice system).  Some of those living in such houses are probably using or will relapse, and this can make it difficult for others to stay sober.

Many sober/halfway houses refuse to accept people in methadone treatment.  This is apparently a “philosophical” decision.  It is a counter-productive policy however, because it denies people in recovery access to housing options that may be helpful to them, and pushes away residents with a higher likelihood of stability in favor of residents with a higher likelihood of instability.

Opiate-dependent people in methadone treatment are generally more stable in their recovery than their peers who are not in medication-assisted treatment.  This is especially true for those in early recovery, and those with complex addiction.

Suboxone/Subutex (buprenorphine)

Buprenorphine (brand name Subutex, and brand name Suboxone when the formulation includes the drug nalaxone), is a medication used to treat opiate dependence.   Buprenorphine is methadone’s strongest competition in the contest for the title, “Single Most Effective Treatment for Opiate Dependence.”

Buprenorphine treatment shares many of the characteristics of methadone as a medication-assisted treatment for opiate dependence.  Their are two reasons that buprenorphine can’t quite take the Most Effective title away from methadone.

First, buprenorphine has a “ceiling effect.”  This means that at some point, taking a higher dose of buprenorphine will have little or no additional effect.  For some people, there is no effective dose of buprenorphine.  For these people, methadone offers a broader range of effective dosing options.  In this sense, methadone is a “stronger” medication.  Methadone is able to provide a therapeutic dose to a broader range of people with opiate dependence.

Second, buprenorphine is commonly prescribed by private doctors in office-based settings.  This means that the medication usually comes with little monitoring and few supports.  For an opiate-dependent person in early recovery, this can be challenging.  It takes a certain level of recovery stability for a buprenorphine patient to hold their own medication.  This is because buprenorphine has a street value, and can be sold for cash or traded for other drugs.

In contrast, methadone treatment for opiate dependence must be provided in a clinic-based setting.  And under federal law, the clinic must hold the medication for the patient and provide the medication at the clinic in daily doses.  It takes months for patients to earn the right to have limited take home doses under federal regulations.  This can create barriers to treatment and recovery.  But it also supports people in early recovery stabilize in recovery.

In combination, these two differences make methadone a more effective treatment for many people with complex addiction to opiates.

Conclusion

Much maligned and often misunderstood, methadone remains a wonderful gift.  A gift that has saved thousands of lives, held together families, and brought hope and success to many who felt hopeless and defeated by their addiction.

Methadone is not a magic bullet, and it is not an appropriate treatment for everyone.  But if you care about people with opiate dependence, I urge you to speak up and help others understand the value of this important path to recovery.