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Methadone Saves Lives, Stigma Kills People

January 17, 2017

I lost a dear friend over the weekend. I lost him to heroin, but I also lost him to stigma about evidenced based treatments. This friend reached out to me a couple of years ago when he was struggling with heroin addiction. He knew what I did professionally and he believed he would die if he didn’t get help.

I told him about methadone. I explained that it is a synthetic opioid that binds to the same receptor sites in his brain as heroin to relieve craving and withdrawal symptoms. Craving for heroin and other opiates is intense and feels all encompassing. It leads to compulsive searching for drugs to stop the withdrawal symptoms. Withdrawal from opiates won’t kill you, but you will feel like you are going to die. The need to avoid the pain and suffering is the primary motivator for continued opiate use despite all the negative consequences that the addicted person experiences from drug use. Getting on a stable dose of methadone stops all of that so that the addicted person can focus on behavior and thought changes that need to take place in order to remain off drugs.

He was cautious. He had heard bad things about methadone.

“Isn’t it just trading one addiction for another?” No, methadone is an FDA approved medication that treats opioid use disorder, just like insulin is an FDA approved medication that treats type II diabetes.

“Diabetes is different than heroin addiction.” Well, both are medical conditions that manifest due to a complicated combination between genetic predisposition and environmental and behavioral factors. Insulin isn’t a magic cure for diabetes. The medication must be combined with lifestyle changes and hard work to stay healthy. Methadone treatment is similar in that the medication itself is not a cure. It must be combined with lifestyle changes and hard work to achieve recovery.

“Isn’t methadone hard to come off of?” It can be. Most people who are addicted to heroin and other opiates will need to be on their medication for at least 2 years. One year on a stable dose with no withdrawal and craving to reset receptor sites in the brain, and one year to slowly taper off the medication so that withdrawal and subsequent risk for relapse is minimized.

“But I want to be off everything now. Taking medication isn’t recovery. I should look into detox.” Detox is an option and might be an appropriate first step especially if you are using other substances that wouldn’t mix well with methadone, like alcohol or benzos. It lasts about 3-7 days. More than 80% of people need more than detox alone. Methadone or buprenorphine treatment is the gold standard of care in the addiction medicine field for the treatment of opioid use disorder. The problem with detox alone is that the craving and withdrawal isn’t addressed, leading MOST people to use again. After not using for some time in a detox, your body can’t handle the amount of drugs it had been used to taking. This is known as “reverse tolerance” and it kills people. This is why death rates are highest for people addicted to opiates immediately following release from jail and immediately following release from detox.

Our conversations continued along this line for a while, but ultimately he decided to go to treatment. I helped him find a methadone program close by and after a few weeks he felt great. He was able to go to the clinic on the way to work to take his medicine, and work for 9 hours without experiencing any withdrawal. He was able to sleep at night without waking up from night sweats and muscle spasms. He told me he had a “new lease on life.”

Then he relapsed. He was experiencing withdrawals and cravings, but refused to increase his medication dose, even though his counselor was encouraging him to. Because of the stigma of being on the medication, he wanted to be off of it as soon as possible. He believed that by not increasing his dose, it would be easier to taper off. As counterintuitive as it seems, the reality is that if you are starting a taper from a place of withdrawal, the withdrawals will be worse. The highest likelihood of a successful taper depends on getting to what’s called a “steady state” and staying there long enough that your brain can hit the reset button. When you’re at a “steady state,” it should feel like you are taking a vitamin every day. There should be no significant difference between the way you feel before and after you take your medication.

We talked about other changes that he can make to reduce cravings for heroin too. If you are craving a lot when you're home because that's where you always used to use, it can help to change routines around because your brain associates old routines with using and cravings will increase as a result. You may consider rearranging your furniture so that the setup of your room looks different to help stop those associative triggers.

My friend continued down his path of recovery for a while. He got a new job, a car, an apartment, and began cultivating new relationships. But somewhere along the way something happened, and he got disheartened. Several weeks later, against his counselor’s advice and mine, he decided to detox out of his methadone program. He equated methadone with what was ruining his life, instead of what was saving it.

He entered detox, a residential placement, and then a halfway house. There were ups and downs. There were intense cravings, house drama, and job issues. Through it all, he kept me updated. When he really began struggling with relapse, he tried to keep it from me. He was worried about disappointing me and he hated the idea of letting me down. When he was kicked out of his halfway house for using, I reminded him about how well he did when he was in the methadone program. He was determined not to go back to methadone because of the stigma. The halfway house he was trying to get back into was against methadone treatment because they didn’t consider that to be “clean.”

My focus became making sure he was as safe as possible. Stay away from the fentanyl laced heroin, use clean needles, don’t use alone, carry naloxone in case you need to reverse an overdose or someone needs to reverse yours. It’s important for you to know that you did not let me down. Addiction is a very powerful disease and relapse is an unfortunate part of the recovery process. You can learn from this situation and you will be stronger for it. I am going to support you in whatever decision you make, I hope you know that. I also just want you to know that there are many paths to recovery and methadone/buprenorphine is one path. Over 80% of people who are addicted to opiates find that they need medication to stay clean. Just tuck that away in the back of your mind in case you need to go that route.

We stayed in touch. I was there for the ups and the downs, but this weekend he lost the fight. I think stigma against legitimate treatment options killed him just as much as the heroin did.

Abstinence-only treatment works for some people. But for most, it takes a comprehensive medical approach. Unfortunately, in my field, there is a strong abstinence-only stance when it comes to addiction treatment. But the science says that just doesn’t work a majority of the time for opiate addiction. Treatment professionals, families, and people addicted to heroin and other opiates need to understand that there is another option.

Methadone saves lives. Stigma kills people. Rest easy, my friend.

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