Opioid replacement therapy is a physician-assisted method of withdrawal management. This technique involves using specific types of opioid medications that attach to the same receptors in the brain that drugs of abuse do, such as heroin, Vicodin, OxyContin, etc. These medications are specifically designed to eliminate cravings for opiate drugs during the withdrawal process and lessen withdrawal symptoms for individuals attempting to discontinue these drugs. They do not produce euphoria or the psychoactive effects that the drugs of abuse produce.
In most cases, the goal is to slowly administer the drug on a tapering schedule, such that at specific intervals, the dosage of the opioid replacement medication is decreased so the person can be weaned off opioid drugs altogether. Because individuals who abuse opiate drugs often develop very significant physical dependence on them, and the withdrawal process from trying to discontinue the drug is so discomforting and severe, the risk of relapse is extremely high. These replacement medications have far better success in helping individuals to avoid relapse and negotiate the withdrawal process than attempting to withdraw using a “cold turkey” method. Perhaps the most well-known opioid replacement medication is methadone.
What Is Methadone?
Methadone is a man-made opiate drug that attaches to the same receptor sites in the brain as other opiate or narcotic drugs. The use of methadone as an opioid replacement medication began in the 1950s and continues today. Its primary use is as a method of withdrawal management or replacement for heroin in individuals who have developed opioid use disorders. Methadone maintenance treatment can only be provided by programs that are certified by the Substance Abuse and Mental Health Services Administration (SAMHSA) and registered with the United States Drug Enforcement Administration.
There are potential drawbacks to methadone maintenance programs.
- A good number of individuals in methadone replacement programs do not taper off the drug. This means that these individuals continue to be involved in maintaining an opioid use disorder, and they are using methadone as a replacement for some other drug such as heroin. Critics of this practice state that individuals are simply replacing one addiction with another and then justifying addictive behaviors as opposed to actually treating them.
- Methadone replacement therapy is effective for opioid drugs but not effective for other drugs of abuse, such as cocaine. Thus, methadone replacement therapy is not a complete treatment for individuals who have substance use disorders that involve multiple drugs.
- Methadone also produces physical dependence, and anyone who abruptly quits taking methadone will experience withdrawal symptoms.
Methadone Withdrawal
Several different conditions can affect the withdrawal process from any drug. Of course, individual differences in metabolism and emotional makeup will often affect the severity and length of the withdrawal syndrome in any individual. In addition, the length of time one used the drug, the typical amount of the drug one took, whether one mixes the substance with other drugs, and the mode of administration (e.g., injection versus taking the drug orally) affect the withdrawal syndrome. Individuals who took methadone for lengthy periods of time, who took larger amounts or took it more than once a day, who habitually used or abused it with other drugs, and who injected the drug (which is the common mode of administration) will typically experience lengthier and more complicated withdrawal syndromes.
A general outline for withdrawal from methadone when no tapering strategy is used is detailed below.
- The acute symptoms will typically begin to appear within 24-48 hours. Some individuals may experience them earlier. Initial symptoms include muscle aches, pain, nausea, vomiting, fever, chills, sweating, headache, rapid heartbeat, anxiety, irritability, restlessness, lack of appetite, issues with anxiety and depression, and insomnia. Individuals will typically begin to crave the drug once the symptoms begin to appear.
- Within 2-10 days after discontinuation of methadone, the symptoms will usually peak and then begin to slowly subside. The individual will still continue to experience the physical symptoms listed above and may have exacerbations of anxiety, irritability, and restlessness. In rare cases, individuals may experience hallucinations and delusions. For most individuals, the symptoms begin to resolve within seven days.
- Between 10 days and three weeks after discontinuation, individuals will experience a resolution of most of the above symptoms. Symptoms such as anxiety, irritability, restlessness, and cravings may surface intermittently. Individuals may begin to experience feelings of depression.
- After three weeks, most individuals have a full resolution of the physical symptoms. Other symptoms, such as cravings, intermittent issues with anxiety, irritability, motivation loss, depressive feelings, mood swings, etc., may continue. Many sources refer to a protracted withdrawal syndrome or post-acute withdrawal syndrome (PAWS) to describe the potential syndrome that occurs after the physical symptoms of withdrawal have dissipated. The symptoms of this lengthier prospective withdrawal period are typically psychological in nature and consist of issues with cravings, mood swings, irritability, etc., that can leave a person vulnerable to relapse. However, even though many individuals who recover from substance use disorders do experience difficulty for months to years after they have discontinued their drug of abuse, major medical organizations, such as the American Psychiatric Association, have not recognized PAWS as a withdrawal syndrome. Instead, it most likely represents a number of other psychological factors.
The Tapering Process Using Methadone
Obviously, a tapering process would result in a longer process of getting off the drug than quitting it abruptly. A tapering process will also reduce the severity of withdrawal symptoms. According to information provided in the book Mechanisms and Treatment: Opioid Dependence and from SAMHSA:
- Methadone treatment will typically last around 12 months and can continue for more than two years.
- The length of the treatment depends on a number of factors, including the needs of the person, the level of dysfunction exhibited, and the severity of the opioid use disorder.
- The dose given initially is 80-120 mg a day. Dosing is adjusted during the first week of treatment, beginning with a dose of 20-30 mg once daily and then adjusting according to the individual’s reactions.
- Individuals can choose shorter detoxification periods if they wish or opt for long-term maintenance treatment.
- Patients on a tapering schedule receive dose reductions that should be less than 10 percent of the maintenance dose they were on and should be slowly tapered down, with periods of 10-14 days between dose reductions. Patients are always closely monitored for withdrawal symptoms. If the patient is complaining of withdrawal symptoms, the dosage is returned to its previous level, and the tapering is tried at a lower dose reduction once the person has stabilized.
- Patients are always closely monitored for signs of relapse.
Based on this information, treatment length can be quite variable, depending on the initial dose the person received, how much the dose is reduced every 10-14 days, and other factors that are taken into consideration, including issues with potential relapse. Because individuals may experience minor withdrawal symptoms, the process can often be very lengthy. Physicians supervising the withdrawal management program are typically not in a hurry to reduce the individual’s dose of methadone if they are still experiencing withdrawal symptoms.
Despite methadone’s drawbacks, the research is clear that there are significantly fewer relapses and better long-term success rates from heroin abuse when individuals engage in a methadone maintenance program.