Methadone, technology and outcomes

Substance Matters has a post about the use of new technologies in methadone maintenance.

Patients who use a web-based intervention (TES) instead of half of their traditional counseling did better than those with traditional counseling as part of their methadone treatment.

It provokes important questions about the usefulness of new technologies and how they might be used to improve treatment outcomes.

However, what struck me was this graph:

Web based behavioral treatment for substance use disorders as a partial replacement of standard methadone maintenance treatment

This was a twelve month study. This means that subjects who got TES and did better than subjects recieving traditional methadone used opiates (other than methadone) 25 weeks of the year.

That’s a successful intervention?



When Methadonia was first released, there was quite a bit of hand wringing over whether the film inaccurately presented methadone maintenance treatment in a negative light.

Cassie Rodenberg, at The White Noise, who has been spending time with and blogging about homeless addicts in the Bronx says [emphasis mine]:

Some on the streets find methadone worse than an original heroin addiction, while others find the maintenance system workable. The documentary “Methadonia” interviews those in NYC recovery. For those curious, this is the closest thing I’ve seen to those I speak with every day, an accurate portrayal of life for low-income residents struggling with heroin addiction and recovery. Take a look for the stories.

What’s interesting is that anyone who’s spent time around heroin addiction has seen what we see in Methadonia, yet advocates insist it is not the reality of methadone. Yet, the reality they discuss is invisible to us. If we’re to believe them, it has to be on faith.

Cognitive performance of opioid maintenance vs. abstinence

brains! (Photo credit: cloois)


A new study finds lower cognitive functioning in maintenance patients compared with abstinent former users. It also found no difference between methadone patients and buprenorphine patients.



To compare the cognitive performances of maintenance patients (MAIN), abstinent ex-users (ABST) and healthy non-heroin using controls (CON).


Case control study of 125 MAIN (94 subjects maintained on methadone, 31 on buprenorphine), 50 ABST and 50 CON. Neuropsychological tests measuring executive function, working memory, information processing speed, verbal learning and non-verbal learning were administered.


There were no differences between the cognitive profiles of those maintained on methadone or buprenorphine on any administered test. After controlling for confounders, the MAIN group had poorer performance than controls in six of the 13 administered tests, and were poorer than the ABST group in five. The MAIN group exhibited poorer performance in the Haylings Sentence Completion, Matrix Reasoning, Digit Symbol, Logical Memory (immediate and delayed recall), and the Complex Figure Test (immediate recall). There were no differences between the ABST and CON groups on any of the administered tests.


Poorer cognitive performance, across a range of test and domains, was seen amongst maintenance patients, regardless of their maintenance drug. This is a group that is likely might benefit from approaches for managing individuals with cognitive and behavioural difficulties arising from brain dysfunction.




More on methadone


Points is publishing a series on methadone and offers a case for methadone without resorting to describing it as “the most effective treatment for opiate addiction.”

It’s a pretty fair piece. I had only one quibble with the facts of the story. This is unusual and very welcome. However, the author and I disagree starkly about the context and meaning of those facts. (As I pointed out last week, we seem to lower the bar for these addicts.)

It opens with this statement:

…there is one treatment that offers real hope.

Okay hope is good. Hope for what?

Reduced Crime

One of methadone’s biggest strengths is reducing this criminal behavior. The vast majority of research shows a marked decrease in crime following methadone treatment.  One particularly large study, involving over 600 patients, showed a 70.8 percent decline in “crime days” – a 24 hour period in which an individual commits one or more crimes – during the first 4 months of methadone maintenance treatment.

Reduced HIV Transmission

The post erroneously reports that, “More than 36% of new A.I.D.S. cases are attributed to intravenous drug abuse.” The report they cite actually says:

Since the epidemic began, injection drug use has directly and indirectly accounted for more than one-third (36%) of AIDS cases in the United States. This disturbing trend appears to be continuing. Of the 42,156 new cases of AIDS reported in 2000, 11,635 (28%) were IDU-associated.

These numbers includes people whose only exposure was IDU and people who reported possible IDU transmission AND male-to-male sexual transmission. A more recent report puts these new case transmission numbers significantly lower. Among men, IDU transmission was reported in 7% of cases. (IDU and male-to-male exposure was reported in another 4% of new male cases.) Among women, IDU transmission was reported in 14% of new cases. The total for all 3 groups would be 5594 new IDU-associated cases.

At any rate, the argument is as follows:

Even though methadone does not stop some addicts from continuing IV drug abuse, it reduces that needle share rate to 1/5.   In addition to reducing H.I.V. infections, methadone reduces prostitution by addicts, another major cause of new infections.

Reduced Drug Use

When measuring whether a treatment is effective or not, the primary concern is whether addicts stop or use fewer drugs than before they started treatment.  Methadone succeeds in this regard.  Drug use declines dramatically in those who undergo treatment, and it continues to decline as addicts spend more time in treatment.  Relatively new research shows that addicts who receive higher doses (measured as 80-100 milligrams) use even fewer opiates than the traditional treatment population, who are usually maintained on a sub-optimal dose.

A Couple of Qualifiers


However, the majority of patients drop out within a year.


Nearly 40 percent of patients drop out of methadone programs during their first year of treatment due to incarceration.

What about Abstinence?

Abstinence is dismissed as absolutist and simplistic.

Defining success is of critical importance when assessing any treatment’s effectiveness.  The simplistic view looks at whether a treatment stops an addict from using their drug of choice.  This absolutist approach is problematic for a number of reasons.



Road traffic crashes and prescribed methadone and buprenorphine

Last year, a study questioned whether buprenorphine patients should be allowed to drive because 60% tested positive for other drugs.

Now, another study reaches similar findings:


Opioids have been shown to impair psychomotor and cognitive functioning in healthy volunteers with no history of opioid abuse. Few or no significant effects have been found in opioid-dependant patients in experimental or driving simulation studies. The risk of road traffic crash among patients under buprenorphine or methadone has not been subject to epidemiological investigation so far. The objective was to investigate the association between the risk of being responsible for a road traffic crash and the use of buprenorphine and methadone.


Data from three French national databases were extracted and matched: the national health care insurance database, police reports, and the national police database of injurious crashes. Case–control analysis comparing responsible versus non responsible drivers was conducted.


72,685 drivers involved in an injurious crash in France over the July 2005–May 2008 period, were identified by their national health care number. The 196 drivers exposed to buprenorphine or methadone on the day of crash were young, essentially males, with an important co-consumption of other substances (alcohol and benzodiazepines). Injured drivers exposed to buprenorphine or methadone on the day of crash, had an increased risk of being responsible for the crash (odds ratio (OR)=2.02, 95% confidence interval (CI): 1.40 and 2.91).


Users of methadone and buprenorphine were at increased risk of being responsible for injurious road traffic crashes. The increased risk could be explained by the combined effect of risky behaviors and treatments.