The Positive Effects of Psychotherapy

on Methadone Maintenance Treatment

Heather Altman

May 8, 2002

Created by the I. G. Farbenindustrie laboratory at Hochst am Main late in the Second World War as a substitute for morphine when Germany had their opium supplies cut off, methadone's action is primarily similar to that of heroin.  And just like heroin, morphine is addictive. Given orally, there are two factors that generally can not be disputed: (1) methadone can prevent heroin withdrawal symptoms while producing little or no euphoria and (2) due to its 24-hour half life, it can replace a heroin addicts' five to eight daily shots. In addition, methadone is not toxic to any bodily organs, even after prolonged use, if only reasonable dosages are used (Judson, 108).

By 1963, "doctors and public health workers had concluded what objective observers and users alike had known for decades: there was no known treatment which could cure more than a small fraction of long term opiate addicts. Every imaginable option had been implemented from lobotomies to insulin shock to psychoanalysis and the threat of lifetime incarceration, but in every case, the results were about the same: between seventy and ninety percent of these chronic addicts would return to their drug of choice in a short time. Due to the statistical analysis in 1963, a number of panels decided that it was time to allow physicians to prescribe the addicts the opiates that they needed" (National Alliance of Methadone Advocates, 2002).

Doctors Vincent Dole (an expert in metabolic disorders) and Marie Nyswander (a psychiatrist who had worked with addicts in Lexington Kentucky) came together at Rockefeller University in New York to experiment with heroin addicts. The researchers tried everything from morphine to dilaudid but found that it was extremely difficult to stabilize the subjects. The addicts were either over sedated or in mild withdrawal most of the time. They mostly spent their days either ‘nodding out’, waiting for their next ‘fix’ or comparing ‘war stories.’ Reluctantly, doctors Dole and Nyswander concluded that the experiment had been a failure and decided to detoxify the patients and release them from the hospital. To withdraw them, they decided to use the synthetic narcotic called methadone. The drug seemed like a very cheap, significantly orally active and longer lasting alternative to opiates such as morphine and it seemed like a convenient way to end the experiment with maintenance. (Waldorf, 11-7)

Unexpectedly, after a few days, the patients had begun to exhibit very different behavior. For weeks they had either been feeling the effects of the narcotics or complaining about their need for more, but their attention was strangely not on drugs all the time anymore. The patients, who were all very similar upon arrival, now began to change. They started to turn back to who and what they were before they became addicted and spent all of their time chasing down drugs (Goldstein, 164).

"These were the reported results:

·     The most dramatic effect of this treatment has been the disappearance of narcotic hunger.

·     [The-subjects} have stopped dreaming about drugs, and seldom talk about drugs when together.

·     These subjects found that they did not "get high" when "shooting" diacetylmorphine with addict friends on the street.

·     Mental and neuromuscular functions appear unaffected.

Even though Nyswander and Dole viewed methadone treatment as a physiological treatment for a physiological disorder, their initial attempts to use methadone- maintenance were combined with intensive psychosocial rehabilitation. Many of their patients clearly derived great benefit from this innovative treatment" (Glasscote, et al., 54-69).

Methadone use for an extended period often results in a few adverse side effects such as constipation, increased sweating, libido and orgasm alterations, menstrual irregularities, insomnia, drowsiness and changes in appetite. Most of these symptoms tend to disappear within the first few weeks of treatment (Bennett, et at, 80 and 143).

Since the original research with Dole and Nyswander the safety of methadone has been proven. "All indicators of general health improve, abnormalities of body systems (such as hormones) tend to normalize....methadone maintenance has no adverse effects on cognitive or psychomotor function....performance of skilled tasks or memory (Goldstein, 165).

The purpose of methadone maintenance is to rehabilitate severe opiate addicts who have tried many other avenues of getting sober and none of them ever seemed to take hold. The four main goals of MMT are: 

1) Increase in social productivity as measured by employment, schooling, vocational training, or homemaker activities.

2) Freedom from heroin "hunger" as measured by repeated negative urine specimens.

3) Decrease in antisocial behavior as measured by arrest and/or incarcerations (jail), as compared with previous experience.

4) Recognition of and willingness to accept help to accept help for excessive use of alcohol and other drugs, or for psychiatric problems. (Bennett, et al. 144)

Like many diseases, drug addiction is preventable. However, once people have progressed to a state of dependence, whether by choice, environmental circumstances or due to a genetic predisposition, they are just as medically as patients with hypertension, diabetes and even cancer. Just as in these diseases, there are medications that help to take care of some aspects of addiction. Yet, one of the most important medications for addiction is that of therapy, which is what makes, methadone maintenance combined with behavioral therapy so effective. However, as with all diseases and therapies, nothing works well with out patient compliance and failure to comply with advice from medical professionals may be one of the worst problems in American health care.

Contingency management is related to the concept of B. F. Skinner’s ideas on classical conditioning and shaping; if a behavior and/or action is rewarded, it is likely to occur again in the future. Such as a boss promoting an employee for excellent work. This theory is put into practice in the world on a daily basis without people ever realizing that it is going on. Nevertheless, in the case of drugs, contingency management is used in some methadone maintenance programs here in the United States. Many MMT programs use rewards such as a take home supply of methadone or vouchers for services or goods for people who have stayed abstinent and had clean urines. "Not only can abstinence be reinforced using these contingency management techniques, but variations of these procedures are effective in modifying other behavior patterns of substance abusers. Reinforcement can be provided for attendance at therapy sessions (Carey and Carey, 1990), for prosocial behaviors within the clinic (Petry, et al., 1998) or for compliance with goal related activities (Bickel, et al., 1997; Iguchi, et al., 1998; Petry, et al., 2000) toward their treatment plans. (Petry, 2002)

Therapy in most all situations is good, however therapy alone is not a sufficient form of treatment for opiate addicts. It is "shown to have little patient interest and low chance of success" (Woody et al., 1998). When drug counseling is combined with methadone maintenance, it has shown to have excellent results for those with moderate to severe levels of psychiatric symptoms (Azar, 1998).

Even without psychotherapy in the treatment package, many heroin addicts find that it is difficult to become enrolled in a program; if they succeed, they are lucky to get a good counselor who sees them regularly. The outcome of therapy often depends on whom it is that does the therapy therefore making it difficult to separate therapy from the therapist. Many opiate addicts have psychiatric disorders and these disorders seem to intensify the course of the addiction. The patients then are best served in combining the drug therapy with the methadone maintenance and even better if the therapy is done by psychiatrically trained therapists. It seems though that most of these programs do not staff people who have psychiatric training therefore most of the psychiatric problems ware never investigated. A criticism of these typical staffing patterns was that treatment of some of the most disturbed people in the public health system had been delegated to persons with the least psychiatric training. Since the combination of psycho— and pharmacotherapy is usually helpful among non-addicts, the question that came about was: "Would psychotherapy improve outcome if it were added to methadone maintenance and drug counseling? NIDA (National Institute on Drug Abuse) funded two studies to research this question in the late 1970's and they were followed by two related studies in the early 1990's.

Study One was done at Yale University and the other at the University of Pennsylvania Veteran's Administration Medical Center (PennNA). Each involved random assignment of methadone-maintained heroin addicts to either paraprofessional drug counseling alone (DC) or counseling plus psychotherapy. Interpersonal psychotherapy (IPT) was used at Yale and Supportive-Expressive (SE) or Cognitive-Behavioral (CB) therapy was used at PennNA... Psychotherapy was made available to subjects for six months with follow-ups at seven and 12 months. The Addiction Severity Index (ASI) evaluated outcome, measured psychiatric symptoms and urine test results... The average dose of methadone was 40 to 50 milligrams in each program.  Most patients had a current or past psychiatric disorder in addition to heroin addiction, and all groups improved.  However, the psychotherapy results differed. The Yale study found no difference in outcome between counseling and psychotherapy (Rounsaville et al., 1983), while the PennNA study found that psychotherapy patients did better (Woody, et al., 1995).

The study of "Methadone Maintenance vs. 180-Day Psychosocially Enriched Detoxification for Treatment of Opioid Dependence; A Randomized Controlled Trial took place between May 1995 and April 1999.  It was used to "compare outcomes of patients with opioid dependence treated with MMT vs. psychosocially enriched 180-day methadone-assisted detoxification" (Sees, et al., 1999). The research was conducted in an already established treatment center. There were 179 adults who were addicted to opiates; they were all integrated into either-r one of the two sections. 154 patients finished 12 weeks of follow-up (Sees, et al., 1999). The study showed that the patients in the MMT program had much better results with a markedly lower use of opiates than the detox group. (Sees, et al., 1999).

According to Sharon Hall, Ph.D., the studies' laboratory director, "the goal of the study was to determine whether short-term methadone-assisted detoxification, when enriched with intensive psychosocial services and aftercare, could provide an effective alternative to methadone therapy. Our results show that no matter how ideologically attractive the notion of a time-limited methadone treatment for heroin abusers, long-term methadone- maintenance treatment is far more effective!” (Alcoholism & Drug Abuse Weekly, March, 2000).

Behavioral therapies are pivotal to successful methadone maintenance treatment. Lewis Judd, M.D., the chairman of the consensus committee, reported that according to scientific data methadone maintenance "combined with psychosocial treatment including counseling and vocational rehabilitation significantly enhances positive clinical outcomes... psychosocial treatment without methadone is not effective.” (Alcoholism and Drug Abuse Weekly, March 1998). Methadone is an important treatment resource for heroin addicts who have reached the end of the line, treatment wise, to be able to reduce their cravings and heroin consumed thoughts so that they can deal with what actually keeps them coming back to it. It is more than just the biological aspect; it is the psychological, social and emotional aspects that need to be treated as well. Treating with methadone is fine to help with the physiological, but without treating the rest of the disease, they are fighting a losing battle. It would be like a diabetic taking insulin and then going out and eating an entire cake.

The longer patients stay on the maintenance program, with a high enough dose, the better their chances that they would be able to stay abstinent. Abstinence also depends upon the attitude of the patient. Are they motivated, do they have a good rapport with their therapist and are they adjusting psychosocially? (Alcoholism and Drug Abuse Weekly, March 1998).

According to D. Dwayne Simpson, Ph.D., director of Behavioral research at Texas Christian University "Several cognitive-behavioral techniques can influence whether patients become engaged by a treatment program. For example, patients are more likely to participate in a program that rewards continued abstinence with vouchers for food, housing or clothes or even gold stars” (Alcoholism and Drug Abuse Weekly, March 1998).

Without any form of therapy, after detoxification, the cravings are still there and without the tools to know how to deal with it, some addicts go right back to their opiate of choice. Methadone makes it possible for people to fuction in the outside world while being treated. They can work, go to school, and raise their children and all with out chasing their drugs, steallng, and lying to everyone that they know. Methadone, if prescribed correctly and used with therapy, has a chance of being extremely effective if the patient truly wants it to work. A dose of methadone over 50 milligrams makes it possible where a patient could use heroin yet not feel its effects. "Although the response rate of methadone is 1ess than perfect, before methadone, there was no way to effect the positive outcome of the one third of patients who vacillate between good and bad. Methadone, for most opioid dependant persons, is not a cure, but substantial benefits result from its proper use" (Holmes, 1999).

It is evident through research and studies that in the fifty plus years since methadone was invented there has not been a better way to treat chronic heroin addicts. They are working on new drugs such as Buprenorphine, Naltfexone and Naloxone, but these still have a ways to go. Paired with psychotherapy and maybe even contingency management, there is no real excuse for the addict who wants to get off drugs but may be afraid to just stop to not get into a methadone maintenance program and do very well. Unfortunately though, some methadone clinics do not offer any type of real counseling, only case management. That is fine, but it does not address the actual problems at hand. I hope that one day in the near future, all clinics will be equipped with the necessary services to better treat their clients.

WORKS CITED

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