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Alcohol Alert

National Institute on Alcohol Abuse and Alcoholism No. 1 August 1988

Methadone Maintenance and Patients in Alcoholism Treatment

Alcoholic ex-heroin addicts who are in methadone-maintenance treatment can be treated for their alcoholism without first withdrawing them from methadone, according to the results of clinical research.

Alcoholism treatment programs have frequently had a policy of first taking the ex-heroin addicts off methadone. This policy now has important public health implications.

Intravenous (IV) drug abusers are the second largest risk group for AIDS, after homosexual and bisexual men. With the recent reduction in the rate of new human immunodeficiency virus (HIV) infection among homosexuals and bisexuals, IV drug abusers have become the primary target far intervention to halt the spread of the disease.

About 25 percent of the nearly 1 million chronic IV drug abusers in the United States are HIV seropositive, and approximately 26 percent of all reported AIDS cases in the United States have occurred among this risk group.(1,2) Intravenous drug abuse also is considered to be the direct or indirect source of most of the AIDS cases among mothers and their newborns.(1-3) Prompt intervention among this risk group will protect seronegative IV drug abusers and their sexual partners, as well as pregnant mothers and their children.

Successful intervention strategies among IV drug abusers, however, must overcome the problem of narcotic addiction. Since 1965, methadone-maintenance programs have proved to be the most effective treatment for IV opiate (e.g., heroin) addiction. When properly supervised, a daily dose of 60-100 mg of methadone prevents withdrawal symptoms and drug "hunger," produces no euphoria, and enables patients to return to a normal lifestyle. The effectiveness of methadone treatment has been demonstrated by reductions in criminal arrests, increases in employment, and stability of social relationships.(4,5) (Methadone maintenance has no role, nor was it designed to have a role, in the treatment of any addiction other than opiate addiction.)

More than 150,000 heroin addicts have been treated with methadone, and nearly 100,000 are currently enrolled in programs in the United States.(6) Between 55 and 80 percent of addicts remain voluntarily enrolled in methadone-maintenance programs for at least 2 years; fewer than 10 percent of these patients continue to abuse heroin while in treatment. (4,6)

The observed 90 percent reduction of IV heroin use among methadone-maintained patients can substantially reduce the risk of HIV infection and AIDS. A study conducted in 1984 of methadone-maintained patients in New York City compared patients who had been in continuous treatment prior to 1978 (the year HIV infection became apparent in New York) with patients who had not been in continuous treatment since 1978. Results indicated that fewer than 10 percent of the patients who had been in continuous treatment prior to 1978 were seropositive for HIV, compared with 47 percent of patients who had not been in continuous treatment since 1978.(7)

An early concern with methadone-maintenance treatment was whether it was harmful to various organ systems. Since then, several studies have indicated that high daily oral doses of methadone are safe, although there are a few side effects, such as increased sweating, chronic constipation, sexual dysfunction, and sleep abnormalities. These side effects are not considered serious, and they often disappear after the first 6 months of treatment.(8-10) Studies of methadone's effect on the liver have shown that methadone is not toxic to this organ, even in patients with severe chronic liver disease.(8,11,12) < P ALIGN="LEFT"> It also has been suggested that methadone reduces the effectiveness of the body's immune system, a critical complication that, if true, could have serious consequences for the acquisition of AIDS. Although immunology alterations are common among methadone-maintained patients, these alterations are largely attributable to preexisting chronic liver disease (caused by hepatitis or alcohol abuse), an illness common among IV drug abusers, and not attributable to methadone.(9,13)

In fact, at least one study has shown an improvement, over time, in the immunology status of methadone-maintained patients.(13) Laboratory studies of the toxic effects of morphine versus methadone on cells derived from the immune systems of animals and humans have found that methadone either was not toxic or displayed a much lower toxic potentiality than morphine.(14,15)

Alcoholism is a common problem among people in methadone programs, affecting as many as half of such patients.(6,9,16,17) Consequently, many methadone-maintained patients need to be treated simultaneously for alcoholism. Methadone-maintained patients enter alcohol treatment for the same reasons as other alcoholics. In addition to the benefits that all alcoholics derive from treatment, methadone-maintained patients, because of their high rate of chronic liver disease, receive an extra benefit: prevention of further damage to the liver.

Once a patient is admitted to a methadone-maintenance program, it is important that treatment be continuous and long term. When treatment is suspended, it is estimated that from 55 to 80 percent of patients relapse to illicit IV drug use within 2 years.(5) The result of this high relapse rate is an increase in the risk of hepatitis and HIV infection (and ultimately AIDS) and the spread of these diseases.

Questions have been raised concerning methadone maintenance in combination with alcoholism treatment. First, some concern exists over the possible adverse interaction between methadone and sedatives during detoxification and between methadone and disulfiram (Antabuse) during long-term treatment. However, to date, research indicates that interactions between methadone and these other drugs are minimal and that no modifications in dosage have to be made to any of the drugs, although more research is needed on the long-term effects of these interactions.(18-21)

Second, it has been suggested that methadone-maintained patients are not suitable for long-term Support such as that offered by Alcoholics Anonymous. However, researchers have concluded, based on studies of alcoholic methadone-maintained patients, that "[t]reatment for alcoholism in methadone patients should follow the time-tested approaches of the alcoholism field."(22)

A Commentary by NIAAA Director Enoch Gordis, M.D.

AIDS is a major public health threat--arguably the most urgent health threat facing our Nation through the end of the century, if not beyond. To date, the contribution of the alcohol field to the national AIDS effort has focused principally on how to treat alcohol abusers and alcoholics who are HIV infected or who suffer from AlDS-related complex or AIDS. In fact, the speed with which this guidance was provided by alcohol-related organizations is impressive and commendable

Now the alcoholism field. particularly the treatment community. has an opportunity to demonstrate. once more, its ability to meet new challenges in a prompt and decisive fashion by confronting and resolving an issue with significant implications for preventing the spread of HIV infection. That issue is treating methadone-maintained alcoholics in alcohol treatment programs.

Despite the ongoing philosophical debate surrounding the use of methadone maintenance in drug abuse treatment, the fact remains that a good number of former heroin addicts have been able to return to normal func tioning due to methadone maintenance. We know that there is a great need for alcoholism treatment in this population; the prevalence of alcoholism among individuals on methadone maintenance is some 50 percent. We also know that relapse rates are high--70 to 80 percent--among addicts who discontinue methadone maintenance. AIDS is spreading most rapidly now among IV drug users, their sexual partners, and the children of women who are HIV infected. Preventing relapse to IV drug use, therefore, is a significant step toward containing the spread of AIDS.

This, then, is the problem facing the alcohol field. Many alcohol treatment programs require patients to terminate their use of methadone as a condition of admittance for treatment, forcing alcoholics who are methadone maintained to choose between two equally untenable options: They may choose to continue with methadone maintenance and risk disability and death from the chronic health problems of untreated alcoholism, or they may choose to discontinue methadone maintenance and risk drug use relapse and developing and spreading HIV infection.

For many years, I directed a target alcohol treatment program where methadone-maintained individuals, while continuing on methadone, were successfully detoxified from alcohol and treated within the frame of existing alcoholism treatment modalities, including chemotherapeutic treatments and long-term support through AA. I do not believe that alcohol treatment providers need fear or be reluctant to do likewise. Based on my experience. l would argue that even if AIDS prevention were not at issue, there is no justifiable reason to deny treatment in an alcohol treatment program to alcoholics who are well stabilized on a program of methadone maintenance.

Once the pharmacology of methadone maintenance is understood, it becomes clear that treating methadone-maintained individuals is compatible with good clinical management of alcoholism. Methadone, as used in a methadone-maintenance program, is pharmacologically different from heroin and alcohol. It eliminates the body's physical craving for heroin without producing euphoria, allowing former heroin users to stabilize their lives and return to normal patterns of living. There also is little adverse interaction between methadone and other chemotherapeutic agents (e.g., disulfiram) used in alcoholism treatment. Neither does methadone maintenance interfere in the successful utilization of long-term alcoholism treatment, including participation in AA (23,24) Perhaps it is best stated by Vincent P Dole, MD.., a nonalcoholic trustee of AA and co-originator of methadone-maintenance treatment: "It would be more reasonable to consider heroin addiction as a medical problem separate from alcoholism just as a person with both heart disease and alcoholism could receive digitalis from his doctor and still be welcomed into an AA group." (25)

When the data are examined on the effectiveness of methadone maintenance in preventing IV heroin use, on the degree of alcoholism among former IV heroin users in methadone-maintenance programs. and on the alcoholic's risk for deteriorating health conditions. such as chronic liver damage. it becomes clear that requiring individuals to terminate methadone maintenance as a condition of acceptance into alcoholism treatment should be rejected as a standard practice by alcohol treatment service providers.

We hope the information presented in this first issue of Alcohol Alert will encourage acceptance of methadone-maintained alcoholics in alcohol treatment programs and continuation of methadone maintenance during long-term alcoholism treatment.


1. Dondero, T.J., and the HIV Data Analysis Team. Human immunodeficiency virus infection in the United States: A review of current knowledge. MMWR Supplement. Centers for Disease Control, U.S. Dept. of Health and Human Services. 36{S-6), 1987. 2 . Novick, D.M.; Khan. l.; and Kreek, M.J. Acquired immunodeficiency syndrome and infection with hepatitis viruses in individuals abusing drugs by injection. Bull. Narc. 30(1 -2):15-25, 1986. 3. Des Jarlais. D.C.; Friedman, S.R.; and Hopkins, W. Risk reduction for acquired immunodeficiency syndrome among intravenous drug users. Ann. Intern. Med. 103:755-759, 1985. 4. Dole, V.P., and Joseph, H. Long-term outcome of patients treated with methadone maintenance. Ann. NY Acad. Sci. 311:181-189, 1978. 5. Dole, V.P., and Nyswander, M.E. Methadone maintenance treatment: A ten-year perspective. JAMA 235:2117-2119, 1976. 6. Kreek, M.J. Opiate-ethanol interactions: Implications for the biological basis and treatment of combined addictive diseases. In: Proceedings of the 49th Annual Scientific Meeting of the Committee on Problems of Drug Dependence, Harris, L S. (ed.). NIDA Research Monograph 81, in press. 7. Novick, D.M.; Kreek, M.J.; Des Jarlais, D.C.; Spira, T.J.; Khuri, E.T.; Ragunath, J.; Kalyanaraman, V.S.; Gelb, A.M.; and Miescher, A. Antibody to LAV, the putative agent of AIDS, in parenteral drug abusers and methadone maintained patients. In: Proceedings of the 47th Annual Scientific Meeting of the Committee on Problems of Drug Dependence, Harris, L S. (ed.). NIDA Research Monograph 67:318-320, 1986, DHHS Pub. No. (ADM) 86-1448. 8. Kreek, M.J. Medical safety and side effects of methadone in tolerant individuals. JAMA 223:665-668, 1973. 9. Kreek, M.J. Medical complications in methadone patients. Ann. NY Acad. Sci. 311:110-134, 1978..10. Kreek, M.J. Health consequences associated with the use of methadone. In: Research on the Treatment of Narcotic Addiction, Cooper, J.R.; Altman, F.; Brown. B.S.; and Czechowicz. D. (eds.). U.S. Dept. Health and Human Services, Washington, DC, 1983, DHHS Pub. No. (ADM) 83-1281. 11. Novick, D.M.; Kreek, M.J.; Arms, P.A.; Lau, L.L.; Yancovitz, S.R.; and Gelb, A.M. Effect of severe alcoholic liver disease on the disposition of methadone in maintenance patients. Alcoholism: Clin. Exp. Res. 9(4): 349-354, 1985. 12. Beverley, C.L.; Kreek, M.J.; Wells, A.O.; and Curtis, J.L. Effects of alcohol abuse on progression of liver disease in methadone-maintained patients. In: Proceedings of the 41st Annual Scientific Meeting of the Committee on Problems of Drug Dependence, Harris, LS. (ed.). NIDA Research Monograph 27:399-401, 1979. 13. Kreek, M.J.; Khuri, E.; Fahey, L.; Miescher, A.; Arms, P.; Spagnoli, D.; Craig, J.; Millman, R.; and Harte, E.H. Long-term followup studies of the medical status of adolescent former heroin addicts in chronic methadone maintenance treatment: Liver disease and immune status. In: Proceedings on the 47th Annual Scientific Meeting of the Committee on Problems of Drug Dependence, Harris, LS. (ed.). NIDA Research Monograph 67:307-309, 1986, DHHS Pub. No.. (ADM) 86-1448. 14. Tubaro, E.; Avico, U.; Santiangeli, C.; Zuccaro, P.; Cavallo, G.; Pacifici, R.; Croce, C.; and Borelli. G. Morphine and methadone impact on human phygocytic physiology. Int. J. Immunopharmacol. 7(6):865-874, 1985. 15. Tubaro, E.; Santiangelli, C.; Belogi, L.; Borrelli, G.; Cavallo, G.; and Croce. C. Methadone vs morphine: Comparison of their effects on phagocytic functions. Int. J. Immunopharmacol . 9(1):79-88, 1987. 16. Birhari, B. Alcoholism and methadone maintenance. Am. J. Drug Alcohol Abuse 1 :79-87, 1974. 17.Stimmel, B.; Vernace, S.; and Tobias, H. Hepatic dysfunction in heroin addicts: The role of alcohol. JAMA 222:811-812, 1972. 18. Kreek, M.J.; Gutjahr, C.L.; Garfield, J.W.; Bowen, D.V.; and Field, F.H. Drug interactions with methadone. Ann. NY Acad. Sci. 281 :350-370, 1976. 19. Liebson, I.; Bigelow, G.; and Flamer, R. Alcoholism among methadone patients: A specific treatment method. Am. J. Psychiatry 130:483-485, 1973. 20.Liebson, I.; Tommasello, A.; and Bigelow, G. A behavioral treatment of alcoholic methadone patients. Ann. Int. Med. 89:342-344, 1978. 21. Tong, T.G.; Benowitz, N.L; and Kreek, M.J. Methadone-disulfiram interaction during methadone maintenance. J. Clin. Pharmacol. 20:506-513, 1980. 22. Khuri, E.T.; Millman, R.B.; Hartman, N.; and Kreek, M.J. Clinical issues concerning alcoholic youthful narcotic abusers. Adv. Alcohol Subst. Abuse 34:69-86, 1984. 23. Obuschowsky, M.A., and Zweben, J.E. Bridging the gap: The methadone client in 12-Step programs. J. Psychoactive drug 19(3):301-302, 1987. 24. Zweben. J.E. Can the patient on medication be sent to 12-step programs? J. Psychoactive Drugs 19(3): 299-300, 1987. 25. Dole, V.P. AA, drug addiction and pills. AA Grapevine. October, 1972.

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