METHADONE MAINTENANCE TREATMENT FOR OPIOID DEPENDENCE
There have been various email messages from colleagues in the former Soviet nations and
Eastern European countries suggesting that American and other “western” governments are not
supportive of methadone maintenance treatment. This is absolutely NOT the case.
With respect to the United States, the Federal government continues to endorse strongly this
form of treatment, and has in fact undertaken to “mainstream” it by replacing decades-old
regulatory oversight of methadone treatment providers with an accreditation process similar to
that which applies to other forms of medical care. The National Institute on Drug Abuse (NIDA),
the official Federal government authority on drugs, has never issued any statement suggesting
lack of support for methadone treatment. To the contrary – it has consistently and repeatedly
stressed that it is the most effective form of care for narcotic addiction. Thus, even 20 years ago
it issued a major compendium on methadone treatment (US Dept. of Health and Human
Services, 1983) which included the forceful conclusion:
The information contained in the book further supports the effectiveness
of methadone and the maintenance modality . . . Of all the available
modalities for treating opiate addicts, the methadone modality has
consistently retained the greatest proportion of admissions for the longest
period of time [and] . . . while patients remain in treatment, their illicit
opiate use and criminal behavior are significantly reduced.
To argue that methadone maintenance is not at least as effective as other
available modalities for treatment this population is to ignore the results
of the best designed research studies and the consensus of a varied group
of experts in the drug/mental health field.
Nothing in the ensuing two decades challenges in the slightest the conclusions quoted above, or
the voluminous evidence upon which they were based. Today, there are more patients receiving
methadone maintenance in the United States (approximately 180,000) than at any time in the
past 30 years.
Elsewhere, methadone has been and remains the primary treatment approach for narcotic
addiction in Australia, Thailand, Hong Kong, Germany, United Kingdom, Ireland, Belgium, The
Netherlands, Switzerland, Austria, Canada, etc. As is true of the United States, there is not a
single Government anywhere in the world that has reversed a position of allowing methadone
treatment. Germany is a dramatic illustration of the OPPOSITE trend: 15 years ago methadone
was essentially illegal in that country; today tens of thousands of patients receive it.
In an April 2001 United Nations evaluation of the Hong Kong methadone programme, it was
As indicated above the primary objective[s] of Hong Kong's methadone treatment
programme[s] is to provide a readily accessible, medically safe, effective and legal
alternative to illegal drug use. The methadone programme seeks to help drug users resume
a normal, productive and crime free life in the community. Increasingly the methadone
treatment clinics have undertaken public health functions such as HIV surveillance, health
education and counseling.
There is no doubt that the Programme has succeeded in many of its objectives.
A large proportion of known drug users in Hong Kong attends the clinics and [methadone]
is the single most popular drug treatment model used by 65% of drug users in treatment.
Furthermore, the clinics, which are strategically located in Hong Kong, offer a first point of
contact with a helping agency for many of Hong Kong's drug users and act as an important
channel for referral to other treatment agencies for those who seek to become drug free. In
addition, the methadone clinics provide an important 'safety net' for drug users at times
when heroin becomes scarce or unavailable...
Several countries have ADDED Buprenorphine to the “substitution” medications that may be
used to care for addicted patients, and some (e.g., France) have rules for Buprenorphine that are
less stringent than for methadone. However, there is no country in which Buprenorphine (or any
other medication) has REPLACED methadone. Thus, France, which probably has a larger
Buprenorphine patient population than any other country, continues to have approximately
10,000 patients maintained on methadone (less than ten years ago there were barely 50 patients
in the entire country receiving it). In fact, an official Health Ministry report released in April
2002 called for expansion of methadone treatment for addiction in France. The report noted the
benefits of substitution treatment generally, and calls for more balance by regularizing the use of
methadone outside of the specialist setting to which it has been restricted to now.
On a global level, in 1996 the 30th World Health Organization (WHO) Expert Committee on
Drug Dependence reviewed drug treatment approaches, including opioid maintenance treatment,
and reaffirmed its 1993 conclusion in its Recommendation 5.2.8:
...The Committee ... reiterated the previous recommendation for treatment with
oral methadone in appropriate cases in spite of the recognized cultural
sensitivities implicated by such a course of action.
The WHO Regional Office for Europe (EURO) has published the document Principles for
preventing HIV infection among drug users, which recommends the use of methadone. This
document is available in Russian.
As for use of heroin by prescription, this approach is being applied on an experimental basis in
several countries (e.g., Germany, Switzerland, The Netherlands, Canada), but the rationale for its
use is consistently stated as an effort to reach those who either refuse to accept or do not respond
favorably to methadone treatment; nowhere has it been suggested that heroin prescribing
REPLACE methadone treatment.
In sum, there remains consistent evidence of methadone treatment’s effectiveness – evidence that
has been reported from countries all over the world for the past 35 years! All reports indicate that
methadone maintenance markedly reduces – if not eliminates altogether – illicit narcotic use in
the majority of patients. This is true regardless of setting, route of administration of heroin,
economic or political environment, concomitant use of other illicit substances, etc. Nor is there
any evidence to support concerns over the safety of this treatment when certain very straight-
forward and unambiguous dosage guidelines are applied (in a nutshell, starting doses no greater
than 30-40 mg per day, and increments no greater than 10 mg twice a week – it’s that simple!)).
It is true that some prescribed methadone is diverted to the street market, and when used by those
for whom it is not intended it can cause potentially fatal overdose. This, however, is widely
accepted as a reflection of the UNMET DEMAND FOR TREATMENT among current heroin
addicts, and is a potent argument for increasing the availability of methadone treatment for all
who want it and need it.
Emma Bonino, Italy
Marco Cappato, Italy
Gianfranco Dell'Alba, Italy
Benedetto Della Vedova, Italy
Olivier Dupuis, Belgium
David Marsh, MD, Canada
Robert Newman, MD, USA
Marco Pannella, Italy
Andre Seidenberg, MD, Switzerland
Michael Trace, United Kingdom
Maurizio Turco, Italy
Alex Wodak, MD, Australia
Thomas Zeltner, Switzerland