About Methadone and Buprenorphine


1 About Methadone and Buprenorphine Revised Second Edition www.drugpolicy.org

2 We are the Drug Policy and we envision Alliance a just society in which the use and regulation of drugs are grounded in science, compassion, health and human rights, in which people are no longer punished for what they put into their own bodies but only for crimes committed against others, and in which the fears, prejudices and punitive prohibitions of today are no more. Please join us. About Methadone and Buprenorphine

3 About Methadone and Buprenorphine Revised Second Edition Copyright ©2006 Drug Policy Alliance. All rights reserved. “Drug Policy Alliance” and the “A Drug Policy Alliance Release” logo are registered trademarks of the Drug Policy Alliance. Printed in the United States of America ISBN: 1- 93 0517-27- 0 No dedicated funds were or will be received from any individual, foundation or corporation in the writing or publishing of this booklet.

4 Table of Contents 3 Acknowledgments Introduction 4 Dependency 6 What is Methadone? 8 10 Buprenorphine Maintenance 11 13 After Methadone Myths & Facts 14 16 Drug Interactions 18 Your Other Doctors Methadone & Women 19 Storing Methadone 21 Concerns about Overdose 22 25 In Case of Overdose 26 Detoxification 28 Methadone & Pain 29 Driving 30 Traveling with Methadone 32 State Substance Abuse Agencies 33 Other Resources 2 About Methadone and Buprenorphine

5 Acknowledgments This is the third printing of this Many thanks to my collaborators, Corinne Carey, JD, Travis Jordan, booklet. The first 300,000 copies Michael McAllister, Sharon Stancliff, were distributed, across the U.S. MD, Ellen Tuchman, PhD, and Peter and internationally, primarily by Vanderkloot for their invaluable advocates. We are deeply grateful to all who helped get the booklet contributions to the research and out to patients, families, treatment writing of this booklet. providers and program staff, Thanks also to Matthew Briggs, policymakers and other interested members of the community. Paul Cherashore, Amanda Davila, About Chris Ford, MD, Ethan Nadelmann, Methadone and Buprenorphine has JD, PhD, Robert Newman, MD, also been translated into Italian, Russian and Spanish. J.Thomas Payte, MD, Shayna Samuels, and Isaac Skelton for their suggestions for improvements. This second edition has been revised to include information about And special thanks to all the metha - buprenorphine, an important treat - done patients, advocates, and their ment option that has emerged as an loved ones that I have met and additional opioid addiction treatment worked with. You are the inspiration to methadone. Future editions of for this. About Methadone and Buprenorphine will provide readers with more comprehensive information about Holly Catania, JD Baron Edmond de Rothschild opioid addiction treatment using buprenorphine. Chemical Dependency Institute 3 www.drugpolicy.org

6 Introduction • People dependent on street opioids You may be reading this book who receive methadone treatment are because you are taking methadone healthier and safer than those who do or because you are thinking about taking methadone – or because you not. They live longer, spend less time in jail and in the hospital, are less care about somebody who is. often infected with HIV, and commit People usually enter methadone fewer crimes. - treatment because they feel over • whelmed by their dependence on Longer periods of methadone heroin or other opioids. But not maintenance are better than shorter - periods. The longer you stay on everyone who comes into metha methadone maintenance, the better done maintenance has the same the overall outcome. Indefinite treat goals. Some people want to stop - taking street opioids for good. Some ment often means life-long extension of good health, HIV seronegativity, want to temporarily stop taking street and freedom from incarceration. opioids. And some want to reduce or re-regulate their use of street opioids. Methadone maintenance is treatment • Some people begin methadone for people who are dependent on with the belief that they will need opioid drugs. It is not a treatment medication indefinitely. Others feel for people whose major problems that they will only need it for a short are with other drugs – such as time. Regardless of what you hope cocaine, alcohol, benzodiazepines, to get from methadone maintenance, or cigarettes. however, all the evidence agrees on these several points: Opioid drugs include all the drugs that come fully or partially from opium and synthetic drugs that have similar effects. Morphine, heroin, codeine, methadone, dilaudid, buprenorphine, LAAM, OxyContin, and fentanyl are opioids. 4 About Methadone and Buprenorphine

7 People dependent on street opioids who receive methadone treatment are healthier and than those safer who do not. 7 www.drugpolicy.org

8 Dependency people with a long history of opioid Opioids have been used for thousands of years, and it has long been known problems have experienced changes that many people who have become to the part of their brains that allows a dependent on opioids have extreme person to feel and function normally. difficulty permanently ending their This part of the brain makes and uses use of them. its own natural opioids. Suffering through the withdrawal The best known of these natural sickness is only part of the problem. opioids are the chemicals known The real difficulty has always been as endorphins. The word endorphin staying off the drugs once the period literally means “the morphine within.” of withdrawal is over. - Indeed, these chemicals are function ally identical to morphine or heroin. Just as in the case of those who are unable to stop smoking, it is difficult We don’t yet understand everything to explain why it is so hard not to that these natural opioids do in the return to the use of opioids. Reasons body, but evidence suggests that include long-term depression, lack of they are involved with pain control, energy, drug cravings, and sudden learning, regulating body tempera - attacks of physical withdrawal sick ture, and many other functions. - ness. Some people find that these It is possible that people who develop problems diminish over time and eventually disappear altogether – a dependency on opioids were but others continue to suffer these born with an endorphin system that symptoms indefinitely, and many makes them particularly vulnerable. For example, we know that addiction of them eventually relapse to their appears to run in some families. regular use of opioids. Relapse often has nothing to do with lack of will power or other personality problems. Instead, it appears that 6 About Methadone and Buprenorphine

9 Addiction might also be related to Relapse often changes in the brain caused by the overuse of heroin or other opioids. has nothing to Or it may be the result of a complex do with lack of relationship between genetics and the environment. We do not yet know will power or exactly how this malfunctioning occurs, or even whether all people other personality who feel unable to stop using opioids problems. have this damage. There is, however, an increasing amount of evidence that many people who find it diffi - cult to end their use of opioids have experienced these physical changes – which are likely to be permanent. There is not yet any test that can determine how much damage a person may have to his or her natural opioid system, or how hard it may be for that person to stay away from opioids. All that we know for sure right now is that relapse is a major feature of opioid dependency. Methadone is not a cure for the problem of opioid dependency. It is a treatment – and one that is effective for only as long as a person continues to take it appropriately. 7 www.drugpolicy.org

10 What is Methadone? Methadone is a long-acting, synthetic drug that was first used in the maintenance treatment of drug addiction in the United States in the 1960s. It is an opioid “agonist,” which means that it acts in a way that is similar to morphine and other narcotic medications. When used in proper doses in maintenance treatment, methadone does not create euphoria, sedation, or an analgesic effect. Doses must be individually determined. The proper maintenance dose is the one at which the cravings stop, without creating the effects of euphoria or sedation. Although methadone is not a single product from a single manufacturer, the active ingredient is always the same: methadone hydrochloride. 8 About Methadone and Buprenorphine

11 All manufacturers add inactive How is methadone different from heroin and other opioids (for - ingredients, such as fillers, preserva example, morphine or dilaudid)? tives and flavorings. Methadone is dispensed orally in different forms, Methadone lasts longer. which include: The body metabolizes methadone differently than it does heroin or morphine. • , also called diskettes. Tablets When a person takes methadone Each one contains 40 milligrams of regularly, it builds up and is stored in methadone, is dissolved in water, and then is administered in an oral dose. the body, so it lasts even longer when • is also dissolved in water. Powder used for maintenance. Most people find that once they’re stabilized on methadone can be dispensed • Liquid a dose of methadone that’s right for with an automated measuring pump. them, a single oral dose will “hold” Dosages can be adjusted to as small as a single milligram. them for at least a full 24-hour day. For some, the effect lasts longer; for Patients have different opinions about others it lasts a shorter time. the various types of methadone. Stability is easier on oral Each methadone provider usually Most people who are methadone. offers a single type of the drug and on a stable, appropriate dose of obtains its supply from one source, which means that patients generally methadone for several weeks will not do not get to choose which form of feel any significant sense of being methadone they get. “high” or “dopesick.” Some patients may feel a “transition” – or temporary, For most people, a single dose of mild glow – for a short time several methadone lasts 24 to 36 hours. hours after being medicated, however. Others may feel slightly “dopesick” prior to taking the day’s dose but most will feel very little or no effect from the proper dose of methadone once they have stabilized. 9 www.drugpolicy.org

12 Buprenorphine By Sharon Stancliff, MD Prescribed in the U.S. as Suboxone or Subutex, buprenorphine is usually Buprenorphine, when appropriately taken daily as tablets to be dissolved prescribed and taken, is an effective, under the tongue. There is little safe medication approved by the effect from the drug if it is swallowed. FDA for use in the treatment of opioid - Suboxone contains not just buprenor addiction. Buprenorphine relieves phine but also naloxone, an opioid withdrawal, reduces craving and antagonist that may precipitate blocks the effects of heroin in ways withdrawal symptoms if injected. similar to methadone. Maintenance For people dependent on any opioid, doses are generally between 12 and taking the first dose of buprenorphine 32 milligrams but (like methadone) when not in withdrawal can result in should be individualized. acute withdrawal symptoms. Unlike methadone, buprenorphine Buprenorphine, like methadone, may be prescribed for treatment of can be used as a short- or long-term opioid addiction by any doctor who detoxification medication or indefi - has received training (available via nitely as a maintenance medication. the Internet or as a one-day course) The risks of relapse following and a waiver from the DEA. This is its detoxification appear to be similar principal advantage over methadone - whether methadone or buprenor for most doctors and patients. Misuse phine (or any drug-free treatment of buprenorphine is less likely than modality) is used. methadone to result in death. A directory of physicians approved to prescribe buprenorphine can be http://buprenorphine. found at samhsa.gov/bwns_locator/. 10 About Methadone and Buprenorphine

13 Maintenance Methadone won’t control a person’s Methadone maintenance is intended to do three things for emotional desire to get high, but an patients who participate: adequate dose of methadone should prevent the overwhelming physical 1. Keep the patient from going into need to use street opioids. The standard initial withdrawal. dose, as currently recommended, “Block” the effects of street 3. is 30 to 40 milligrams a day. After If the dose is high enough, opioids. several days, providers adjust a methadone keeps the patient from patient’s dose as needed. getting much, if any, effect from the usual doses of street opioids. This result is often called the 2. Keep the patient comfortable and free from craving street opioids. “blockade” effect. Having a craving means more than just having a desire to get high. If a person’s opioid tolerance is elevated high enough with It means feeling such a strong need for opioids that people may have methadone treatment, a great deal of heroin would be required regular dreams about using drugs, to overcome it and produce a think about doing drugs to the significant high. exclusion of anything else, and/or do things that they wouldn’t normally do to get drugs. 11 www.drugpolicy.org

14 Methadone won’t control a person’s desire to get high, but an adequate dose of methadone should prevent the overwhelming physical to use street opioids. need About Methadone and Buprenorphine

15 After Methadone staying opioid free over the long Many people who must take term is the harder challenge. Studies medications every day get tired of find that people who have long doing so. This is especially true of patients on methadone maintenance histories of trying and failing to live because, in the United States, almost without opioids will probably not be all methadone patients are also able to stay abstinent for long. required to make frequent visits to a clinic to receive their medication. It isn’t yet possible to predict who For many reasons, most methadone will be able to live life without opioids, but it doesn’t seem to depend on how maintenance patients decide at some point that they want to stop “together” you are. If you are detoxing taking methadone. and find that you are craving opioids, or you have finished detoxing and you are always thinking of opioids, If you do choose to leave mainte - then perhaps maintenance should nance, your provider should reduce be part of your life. your dose at the speed you feel comfortable with. If it is slow enough you should not experience major physical withdrawal symptoms. But if you have tried withdrawing from opioids many times and have relapsed, then you may have found that detoxing is the easier part and 13 www.drugpolicy.org

16 Myths & Facts Myth: Methadone gets into your Myth: Taking methadone damages bones and weakens them. your body. Methadone does not “get into Fact: Fact: People have been taking the bones” or in any other way cause methadone for more than 30 years, harm to the skeletal system. Although and there has been no evidence that some methadone patients report long-term use causes any physical damage. Some people do suffer having aches in their arms and legs, some side effects from methadone the discomfort is probably a mild withdrawal symptom and may be – such as constipation, increased eased by adjusting the dose sweating, and dry mouth – but these of methadone. usually go away over time or with dose adjustments. Other effects, Also, some substances can cause such as menstrual abnormalities and decreased sexual desire, have more rapid metabolism of methadone - (see pages 16-17 for a list of medica been reported by some patients tions that interact with methadone). but have not been clearly linked to methadone use. If you are taking another substance that is affecting the metabolism of Myth: your methadone, your doctor may Methadone is worse for your body than heroin. need to adjust your methadone dose. Myth: Fact: It’s harder to kick Methadone is not worse for methadone than it is to kick your body than heroin. Both heroin a dope habit. and methadone are nontoxic, yet both can be dangerous if taken in excess – but this is true of everything, from Fact: Stopping methadone use is different from kicking a heroin habit. aspirin to food. Methadone is safer than street heroin because it is a Some people find it harder because the withdrawal lasts longer. Others legally prescribed medication and it is taken orally. Unregulated street say that although it lasts longer, it is drugs often contain many harmful milder than heroin withdrawal. additives that are used to “cut” the drug. 14 About Methadone and Buprenorphine

17 Myth: The lower the dose Methadone harms your liver. Myth: of methadone, the better. The liver metabolizes (breaks Fact: down and processes) methadone, Fact: Low doses will reduce but methadone does not “harm” withdrawal symptoms, but higher the liver. Methadone is actually much doses are needed to block the effect of heroin and – most easier for the liver to metabolize important – to cut the craving for - than many other types of medica heroin. Most patients will need tions. People with hepatitis or with severe liver disease can take between 60 and 120 milligrams methadone safely. of methadone a day to stop using heroin. A few patients, however, Myth: Methadone is harmful will feel well with 5 to 10 milligrams; others will need hundreds of to your immune system. milligrams a day in order to feel comfortable. Ideally, patients should Methadone does not damage Fact: the immune system. In fact, several decide on their dose with the help studies suggest that HIV-positive of their physician, and without outside interference or limits. patients who are taking methadone are healthier and live longer than those drug users who are not Myth: Methadone causes drowsiness and sedation. on methadone. All people sometimes feel Fact: Myth: Methadone causes people to use cocaine. drowsy or tired. Patients on a stabilized dose of methadone will Methadone does not cause not feel any more drowsy or sedated Fact: than is normal. people to use cocaine. Many people who use cocaine started taking it before they started methadone maintenance treatment – and many stop using cocaine while they are on maintenance. 15 www.drugpolicy.org

18 Drug Interactions Some medicines slow the metabolism Like any medication, methadone of methadone. Sometimes people can interact with other types of medicines and with street drugs. will feel the effect of methadone more strongly when they take The body is a complex system, and it’s possible that foods, hormones, these medications, and sometimes weight changes, and stress may they experience withdrawal symp - toms when they stop taking these each also affect the way in which methadone works in your body. medications: Amitriptyline (Elavil) • We know about some of the Cimetidine (Tagamet) • substances that may interact with Fluvoxamine (Luvox) • • methadone – and some of them Ketoconazole (Nizoral) are listed here. Others may yet be discovered. Some medications are opioid blockers and may cause withdrawal. These block the effect of methadone These medicines cause the liver should not be taken to metabolize methadone more if you are and quickly and may cause a need for taking methadone: Pentazocine (Talwin) an increased methadone dose: • Naltrexone (Revia) • Carbamazepin (Tegretol) • • Phenytoin (Dilantin) • Tramadol (Ultram), in most cases • Neverapine (Virammune) • Rifampin • Efavirenz (Sustiva) Amprenavir (Agenerase) – • methadone also significantly reduces the level of amprenavir. Ritonavir (Norvir) – less of an effect • 16 About Methadone and Buprenorphine

19 Two things should always be Some medications initially kept in mind regarding interact with methadone to cause methadone interactions: sedation, but then the opposite occurs, and they can cause withdrawal symptoms. These Methadone is not responsible • for every new feeling you have, medications include: Benzodiazepines such as and it won’t be affected by most • Xanax and valium medications or changes in your life conditions. • Alcohol • Barbiturates If your methadone dosage doesn’t • feel right, it probably isn’t right. You Other medications with interactive are the expert when it comes to how effects: Cocaine can increase the dose of • much methadone is enough. Talk to your doctor about how you’re feeling. methadone required. Methadone increases the level • of AZT and desipramine in For more information about drug interactions, go to: the blood. www.hivguidelines.org. Search under “methadone.” If your methadone dosage doesn’t feel right, it probably isn’t right. 17 www.drugpolicy.org

20 Your Other Doctors Methadone patients are sometimes reluctant to tell their other doctors that they are taking methadone. They are afraid that these doctors – or other health- care providers – will discriminate against them. Unfortunately, they are often right. Find a primary-care provider whom you can trust. The ideal situation is to make sure all your doctors know that you are taking metha - done. If you choose not to tell them, however, keep these important things in mind: • If you are having surgery for which • It is illegal for your methadone provider to communicate with your you may be put to sleep, the anesthesiologist might use a type primary-care doctor or anyone else without your written permission. of medication that will cause abrupt (Title 42 of the Code of Federal methadone withdrawal. Be sure you Regulations Part 2 [42CFR part 2] know which medications interact protects against disclosure of drug with methadone (see pages 16-17) – even if your doctors know that you treatment records.) are taking methadone. Ideally, though, open communica - tion among all the doctors who are treating you may assist you in getting the best possible health care. 18 About Methadone and Buprenorphine

21 Methadone & Women You may have heard that you should Is it true that women sometimes stop getting their periods when not take methadone when pregnant. they begin taking methadone? This is not true. • Methadone is not harmful to the Yes, but there are also many other developing fetus – but detoxing is. reasons why women’s periods • Methadone is the treatment of choice become irregular or stop: Pregnancy • for heroin and opioid dependency • Stress during pregnancy. • • Poor diet The effects of methadone on • Weight gain and loss pregnancy have been widely studied. • Menopause Methadone has been used • • Other medical problems successfully during pregnancy. • When properly prescribed for • Other medications pregnant women, methadone provides a non-stressful environment Remember: in which the fetus can develop. • You can still get pregnant even if you • don’t get your period. Taking methadone during pregnancy may prevent miscarriage, fetal You can conceive and have normal • distress, and premature labor. pregnancies and normal deliveries Decreasing the dose of methadone while you are receiving methadone. • during the first trimester increases the risk of miscarriage. • During pregnancy, your dose should be sufficient to avoid cravings, avoid street drugs, and prevent withdrawal. 19 www.drugpolicy.org

22 Methadone & Women (cont.) Babies born to mothers dependent • If you are pregnant, be sure to on methadone will have methadone talk with your doctor, because: in their systems, but studies show • When you’re pregnant, your body that the children can be weaned metabolism changes, so you may successfully and safely with no need to adjust your dosage. You adverse effects. may need to increase your dose of methadone, or split your dose and You may have heard that you shouldn’t breast-feed your baby if take smaller amounts two or three times a day. you are taking methadone, but here are the facts: You may have heard that your baby will be born addicted to methadone • Breast-feeding is now considered safe for the babies of women who are or will suffer other side effects, but taking methadone, but not safe for here are the facts: women who are HIV positive. • Methadone does not cause fetal Small amounts of methadone in • breast milk can pass to the baby. abnormalities. No harmful effects • to a fetus have been found in the Methadone levels in breast milk are study of methadone’s effect on very low. pregnancy. • Premature birth and low birth weight can be associated with cigarette smoking and/or poor nutrition and are not attributed to methadone. 20 About Methadone and Buprenorphine

23 Storing Methadone While at home, always keep your If anyone in methadone in a safe place – preferably out of in a locked box or cabinet – your home the reach of children clearly and accidentally to prevent anyone else from marked taking it accidentally. drinks methadone, Remember: Methadone is a very call 911 or an strong drug. A small amount can ambulance kill a child or an adult who does not have a tolerance to it. If anyone in immediately. your home accidentally drinks your methadone, call 911 or an ambulance immediately. Store your methadone away from extreme heat or cold. The methadone that you take home is often mixed with water – and sometimes mixed with other additives, depending on where you get your methadone. The solution typically lasts for weeks. When you are traveling or away from home, keep your methadone in the prescription bottles that were given to you by your methadone provider to prevent any trouble with the law. As with any prescription drug, it is illegal to possess methadone without a prescription. 21 www.drugpolicy.org

24 Concerns About Overdose If you stop taking methadone and Methadone treatment reduces the chance of overdose for those who are start using street drugs again, your chance of overdose increases using or are addicted to heroin. because you now have a lower Methadone is a pure drug and is tolerance for the drugs. Tolerance increases when your body has individually prescribed. It does not contain the harmful “cuts” that are gotten used to having the drug in its system – in other words, your body mixed into drugs bought on the street. Concerns about overdose “tolerates” the presence of the drug. If you stop using regularly – or if you remain, however, especially if you continue to use street drugs or if have detoxed – it takes a smaller amount of the heroin, methadone, or you resume regular heroin use after other opioid to cause an overdose. stopping your methadone treatment. - Also, mixing pills such as benzodiaz epines, barbiturates and/or alcohol with methadone or heroin increases the risk of overdose. 22 About Methadone and Buprenorphine

25 What if I use other drugs while I am Frequently Asked Questions taking methadone? The correct dosage of methadone Can I overdose on methadone? It is possible to overdose on metha blocks the effects of heroin. If you - done, but providers work to adjust take opioids while also taking metha - dosages so that they are safe for done, you may not feel the effects of each individual patient. It is important the opioids. You may then decide to to be honest with the clinic staff about take even more of the opioid, which how much heroin or other opioids could cause an overdose. Some you are using so that they prescribe a drugs also interact with methadone dosage that is right for you – too little and can change how your medica - won’t be effective; too much could tions affect you (see pages 16-17). cause you to overdose. Methadone Taking too much of a sedative or drinking a lot of alcohol while you is a strong medication, so you need to build up the dosage slowly to be are taking methadone can also be dangerous because each substance sure that your body is handling the medicine well. makes the other more powerful, increasing your risk of overdose. Be extremely careful if you mix Can I overdose on buprenorphine? these drugs. Misuse of buprenorphine is less likely than methadone to result in death (see page 10). The correct dosage of methadone blocks the effects of heroin. 23 www.drugpolicy.org

26 Concerns About Overdose (cont.) Can I overdose on heroin while very careful. Take some precautions – always be sure there are other I am taking methadone? people with you when you’re using, Yes. Even while taking methadone, in case you need medical attention, if you take too much heroin – and test the effect of the drug on especially if the heroin is unusually you before you take an entire dose. strong – you could overdose. You increase the odds of overdosing on heroin while you’re taking What happens if I start taking methadone again after I have methadone if you mix it with stopped? sedatives, alcohol, or other drugs. If you stop taking methadone even for a few days, you need to What if I stop going to my be careful when you start taking methadone program? If you stop taking your methadone it again. Your body may have lost some of its tolerance for the and return to using street drugs, you can overdose more easily than methadone, so you could overdose. when you last used. When you stop You need to restart at a lower dose taking methadone, your body will and work back up to the level you were at when you stopped. rapidly develop a lower tolerance for The doctor at the clinic can help the heroin. As soon as your metha - you determine the right dosages. done completely wears off (a couple of days), your tolerance for heroin will be lower than it was when you began taking methadone. So, if you decide to use again, you need to be 24 About Methadone and Buprenorphine

27 In Case of Overdose If you suspect that someone What should I do if someone has overdosed on methadone, overdoses? • lay the person on his or her side Immediately call 911 and remain with in the recovery position and call the person. 911 immediately. Do not force the person to vomit. • • Do not make them take a cold If medical professionals arrive shower. • quickly, they can treat the Do not inject salt water into their veins. individual with an antagonist, such as naloxone, that will help them come out of the overdose. It is What are the signs of an opioid - important to tell the medical profes overdose? sionals what drug the overdose Unresponsiveness • • victim took so they know which drug Drowsiness to use to counteract the overdose. • Cold, clammy, bluish skin • Reduced heart rate • The person who overdosed will Reduced body temperature need to be watched for a few hours. Slow or no breathing • Methadone is a long-acting drug. The medications that are used to What might happen if an overdose is not treated? treat the overdose are short-acting. If the antagonist wears off before • Brain damage Paralysis (temporary or permanent) the methadone level decreases • Death • enough, the patient may go back into a state of overdose and require medical attention again. 25 www.drugpolicy.org

28 Detoxification of heroin withdrawal. This method Doctors do not advise that people may be successful for people who quickly taper off of their dose of - methadone – but there are, unfor haven’t been dependent on heroin or other opioids for a long time. tunately, many situations where this occurs. For example, a methadone patient may be in jail or in a hospital If you do start using drugs again after where methadone is not prescribed. your detox, you are not a “failure.” Or the person may be complying with Time that you spent away from street a demand from family court in order drugs was a period of reduced risk to be reunited with children who are – risk of arrest, exposure to disease, in foster care. Public policy is slowly and overdose. But remember, if you relapse, the first weeks of use (again) changing, but some methadone are a time of higher risk of overdose. patients are still being forced to detox from their medication. How it Works If you are being “administratively Methadone patients have two options: detoxed” by your methadone inpatient and outpatient treatment. provider, you should find another With inpatient treatment, the patient provider quickly. If your provider is admitted for overnight care to a is not helping you find another, contact a harm reduction program, clinic or hospital. The patient usually needle exchange, or your state’s must spend several days and take medication to relieve the withdrawal health department for assistance. A directory of state alcohol and symptoms. In outpatient detox, medication also provides relief from drug abuse agencies can be found www.treatment.org/states/ at withdrawal symptoms. The medica - tion is administered during daily clinic index.html visits over a period of several weeks or longer. Often methadone is used in Some people also use gradually tapering doses of methadone for a doses that are gradually reduced. short period of time (three to seven days) to relieve the initial discomfort 26 About Methadone and Buprenorphine

29 The usual detox program for Any “cross-tolerant” opioid – such as morphine, dilaudid, methadone, methadone requires that the patient heroin, or LAAM – can suppress use it as a tapering dose for 21 to withdrawal. Methadone is used 30 days. During induction, the doctor - because it is long-acting, gentle, determines the right dose to over come withdrawal. Afterward, the eliminates craving, and does not produce a “high” when it is dose you take gradually becomes used properly. smaller, until you no longer need the methadone. The medical and counseling staff in your program Other medications, including can help you develop a plan for drugs such as buprenorphine and further treatment if you need it, and clonidine, are also used – and may will guide you through the physical be used more widely in the future. changes you experience during the detox period. 27 www.drugpolicy.org

30 Methadone & Pain Severe pain has long been under treated in the United States. This is partly because of ignorance and prejudice, but also because of the laws that made drugs like heroin illegal. The government has actively pursued and prosecuted physicians for prescribing opioids. If you are on methadone maintenance, your regular maintenance dose of methadone will provide little or no pain relief. You will still feel pain, just like everyone else. In fact, you may need more pain-relief medication than people who are not taking methadone. Greater public awareness of how many people have needlessly suffered because of this undertreatment of pain is beginning to force changes. To manage pain, doctors are beginning to more freely prescribe opioids – including methadone, which has been recognized as an effective pain medication. About Methadone and Buprenorphine

31 Driving Discrimination persists, despite Study after study has shown that the fact that people maintained on people who are maintained on a correct dose of methadone can do methadone are no different from the general population in their motor anything that people who are not using any medication can do. skills, reaction times, ability to learn, focus, and make complex judgments. Researchers have conducted laboratory and field studies since Of course, your ability to think and function normally depends on 1964. They have consistently found your having the correct dosage of that methadone – when used in the methadone. If you feel groggy, tired, treatment of heroin addiction – has or unable to focus, you should not no adverse effects on a person’s ability to think and function normally. drive. Be sure to consult your clinician about whether you are receiving a correct amount of methadone. Methadone patients still experience a great deal of discrimination by employers, however, especially when they seek to get or keep jobs that involve driving. 29 www.drugpolicy.org

32 Traveling with Methadone A comprehensive “Methadone Traveling in the United States It can be very stressful for methadone Maintenance Treatment Directory” patients to plan a trip. Rules vary from listing contact information for place to place throughout the United outpatient methadone maintenance States, and many of them are unclear. facilities in the United States can be found on the Internet at: If you are traveling within the United www.findtreatment.samhsa.gov. States, decide whether you want to If you do not have access to the travel with your medication or obtain it Internet, see the directory of state substance abuse agencies on when you arrive at your destination. page 32. To be sure that your methadone treatment is not interrupted, you will Traveling Abroad Methadone is a prescribed medi either need to get enough methadone - from your provider to cover you for cation, and most countries allow the entire time you’re away – or your visitors to bring whatever prescription provider/clinic will need to arrange medications they need with them. In for you to be “guest medicated” at a some places, however, methadone may be considered an exception to methadone clinic located in the area this policy. where you will be staying. In many countries, methadone is In either case, it is wise to make your not available, and some countries arrangements as early as possible prohibit bringing it in. Some countries before you leave. also have laws prohibiting former addicts or people with criminal Keep in mind that federal, state, and clinic regulations limit the amount of records from entering. It may be difficult to find out which laws are in methadone that you can take with effect in which countries – and which you. These rules differ from place to place, so check with your provider to laws are actually enforced. find out about the rules in the areas you plan to visit. 30 About Methadone and Buprenorphine

33 Whichever option you choose, you There are some resources that patients can check to determine the will need to bring your prescription for methadone, and, if you are guest- laws that apply to methadone at their medicating, a letter from your home destinations. Ultimately, however, patients are responsible for deter - provider, explaining your prescription/ dosage. Make these arrangements as mining whether it is legal and/or safe to bring methadone with them when early as possible before your trip. they travel. What should you do if methadone • An excellent place to start is the importation is prohibited at your destination? INDRO Web site at: www.indro-online.de/travel.htm Knowing that their medication is For more information about European • legal, most simply do not declare it at methadone providers, go to: customs unless they are specifically www.q4q.nl/methwork2/home.htm asked to do so. There are, however, severe penalties for importation of You can also check with the • even small, prescribed amounts consulate of the country that you of medications in some countries are traveling to – although not all consulates will be well informed (for example, the death penalty in about methadone. Singapore!). Whichever country you travel to, Each patient will have to weigh this decision very carefully. Many you will need to decide whether you will carry your own methadone methadone patients have traveled to various parts of the world without (where permitted) or find a metha - experiencing any problems. done provider there who will treat you (if one is available). 31 www.drugpolicy.org

34 State Substance Abuse Agencies Nebraska 402.471.7818 334.242.3961 Alabama 775.684.419 0 Nevada 907.465.2071 Alaska Arizona 602.542.1000 6 0 3 . 2 71.6110 New Hampshire 609.292.5760 Arkansas 501.686.9866 New Jersey 800.879.2772 California 505.827.2601 New Mexico New York 303.866.7480 518.473.3460 Colorado Connecticut 860.418.7000 North Carolina 919.733.4670 Delaware 302.255.9399 North Dakota 701.328.8920 District of 614.466.3445 Ohio Oklahoma 405.522.3619 2 0 2 .7 2 7. 8 8 5 7 Columbia 503.945.5763 Florida 850.487.2920 Oregon 404.657.2331 Georgia Pennsylvania 717.7 8 3 . 8 2 0 0 Puerto Rico 808.692.7506 Hawaii 7 8 7.7 6 4 . 3 7 9 5 208.334.5935 Idaho Rhode Island 401.462.4680 South Carolina Illinois 800.843.6154 803.896.5555 South Dakota Indiana 317. 2 3 2 .7 8 0 0 605.773.3123 515.281.4 417 Tennessee 615 .741.19 2 1 Iowa Kansas 785.296.6807 512.206.5000 Texas 801.538.3939 Utah 502.564.2880 Kentucky 802.651.1550 225.342.6717 Vermont Louisiana 800.499.0027 Maine 804.786.3906 Virginia Maryland 877.301.4557 Washington 410.402.86 0 0 617.6 24. 5111 West Virginia 304.558.2276 Massachusetts Wisconsin Michigan 517. 3 3 5 . 0 2 7 8 608.266.2717 651.582.1832 Wyoming Minnesota 307.777.6494 8 7 7. 2 10 . 8 513 Mississippi Missouri 573.751.49 42 Montana 406.444.3964 32 About Methadone and Buprenorphine

35 Other Resources For more information about For information about methadone, please visit: buprenorphine, please visit: Substance Abuse and Mental Addiction Treatment Forum Health Services Administration www.atforum.com http://buprenorphine.samhsa.gov The Baron Edmond de Rothschild The National Alliance of Chemical Dependency Institute www.opiateaddictionrx.info Advocates for Buprenorphine Treatment Centers for Disease Control www.naabt.org www.cdc.gov/idu/facts/ Methadone.htm Drug Policy Alliance www.drugpolicy.org/library/research/ methadone.cfm The National Alliance of Methadone Advocates www.methadone.org Substance Abuse and Mental Health Services Administration http://csat.samhsa.gov/publications/ PDFs/brochure.pdf 33 www.drugpolicy.org

36 The Drug Policy Alliance Please join our fight for the rights About Methadone and published and dignity of methadone patients Buprenorphine to help patients make and the millions of others who healthy and informed treatment suffer the consequences of the decisions with their doctors. As part failed war on drugs. Join the of our broader mission, we also seek Drug Policy Alliance today. to end the prejudices and policies that cause discrimination against all To become a member and help end people in maintenance therapies. the war on drugs, please contact: By educating hundreds of thou - Membership About Methadone sands of readers, Drug Policy Alliance 70 West 36th Street has helped and Buprenorphine 16th floor advance both of these goals, so we’re pleased to offer it for just the cost of New York, NY 10018 212.613.8020 voice production. As a private, nonprofit 212.613.8021 fax organization, however, the Drug @ Policy Alliance relies solely on our membership drugpolicy.org www.drugpolicy.org/join members and contributors for finan - cial support – both to advance drug About For additional copies of policies based on science, health, Methadone and Buprenorphine , compassion and human rights, and please contact the above address, to aid in the distribution of About email us at: Methadone and Buprenorphine and methadone @ drugpolicy.org publications like it. or call: 212.613.8020 DPA AM 0710 About Methadone and Buprenorphine

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