In our recent blog post Methadone: Changing Attitudes, Saving Lives we discussed the benefits of methadone treatment for people struggling with an opioid use disorder. The purpose of that post was to highlight the advantages of methadone treatment – and Medication-Assisted Treatment (MAT) in general – and begin the work of removing the stigma surrounding both methadone and MAT programs.
This is the second post in our Methadone Mythbusters series.
In this post, we’ll dispel a common misconception about methadone treatment:
People use methadone to get high.
We’ll get straight to the facts.
First, it’s true: some people use methadone to get high. It’s a synthetic opioid with mild sedative and euphoric properties similar to other opioids. But those properties are far less intense than in common opioids of abuse such as Oxycontin, Fentanyl, or heroin. There’s a black market for methadone. People buy, sell, and use methadone illegally. This activity occurs outside the purview methadone clinics regulated by the Drug Enforcement Agency (DEA), the Food and Drug Administration (FDA), and other local and federal agencies.
No one disputes that.
The real question here, though, is this:
Do people who participate in methadone programs use methadone to get high?
The answer to that is simple: no.
Not if the individual is in a legitimate methadone clinic that follows all the medical, legal, and ethical guidelines governing methadone treatment. In a clinical setting, it’s close to impossible to use methadone to get high, in the way most people understand the phrase.
We’ll explain why in a moment.
But first, we’ll explain how methadone treatment works.
Methadone Treatment: How it Works
Everything around methadone treatment is highly regulated by the DEA and the FDA. Best practices for methadone treatment are created, monitored for effectiveness, and updated as needed by organizations like the American Association for the Treatment of Opioid Dependence (AATOD) in collaboration with the DEA, FDA, and Centers for Disease Control (CDC). In addition, state and local guidelines determine specific rules for methadone programs in their states and communities.
That’s the first-line answer to how methadone treatment works. It’s also the first-line answer to the question of whether people use methadone to get high. The layers of administration and regulation common to all methadone programs make it difficult to enter one on a whim. They also make it extremely unattractive for anyone chasing a high rather than seeking treatment.
Next, the process of the treatment itself prevents people in methadone programs from using methadone for non-therapeutic purposes. Once a person enters a licensed methadone program, the treatment proceeds in the following sequence of tightly controlled phases: Induction, Stabilization, Action/Maintenance, and Tapering.
Here’s a description of what happens in each phase, based on this article published by the Journal of Addiction Medicine and this chapter of the book Methadone Maintenance: A Counsellor’s Guide to Treatment.
The Induction Phase: Start Low, Go Slow
During the induction phase, several things happen.
First, the patient and their family are educated about the entire methadone treatment process. Medical professionals describe the risks, what to do in case of an accidental overdose. They’re informed of the legal requirements for participating in counseling and therapy in conjunction with methadone treatment. They also explain the fact that it may take several weeks to arrive at a stable dose. Once everything is explained, clinicians document the process this by acquiring formal, written, informed consent and adding it to the patient’s medical file.
Second, the clinical staff collect all information relevant to the treatment. This includes:
- Substance use history. Clinicians gather as much information as possible about the substances used, the length of use, and the amount of use.
- All medical records. Clinicians review a patient’s medical history for the presence of any medical condition that may impact methadone treatment.
- Pharmacy history. Clinician review a patient’s prescription history to get a full picture of the type and dosage of any current medication. They also examine the type, duration, and dosage of any previous medication the patient has taken.
- Prescription Drug Database review. Clinicians review data from prescription drug monitoring programs to identify unreported medications that may affect methadone tolerance or action.
Third, clinicians determine the initial dose of methadone, based on knowledge of:
- All federal regulations regarding initial dosage.
- The properties and actions of methadone.
- Individual patient history and characteristics
- Other medications the patient takes
- The patient’s level of tolerance to methadone
Fourth, clinicians and the patient work together to find a stable dose. The patient and clinicians identify the dosage at which:
- Withdrawal symptoms cease
- Drug hunger or craving ceases
- Euphoric effects of other opioids cease
- Tolerance of the sedative/euphoric effects of methadone is achieved
The Stabilization Phase: Starting Treatment and Counseling
After the clinicians and patient find a dose that meets the criteria above, they move on to the Stabilization Phase. According to the American Society of Addiction Medicine (ASAM), the goal during this phase is to find a maintenance dose that:
“…allows the patient to conduct activities of daily living without intoxication, excessive sedation, withdrawal, or distressing drug craving.”
If the patient has not started to receive counseling, this is the phase in which they do. This is also when an individual in a methadone program must begin participating in social support/12-step programs if they’re available. Federal regulations – and laws – require that anyone participating in a methadone program also receive counseling. In some areas, participants are also required to attend support meetings such as Narcotics Anonymous (NA) or other state-approved substance use disorder treatment programs.
The Action and Maintenance Phase: Making Lifestyle Changes
Once the patient achieves a steady state of methadone in their system, meaning a consistent dosage that meets all treatment criteria, the clinician and the patient monitor the subjective experience of the patient to ensure the dosage is correct. Over time, the maintenance dose may or may not change, depending on a wide range of factors, including but not limited to stress, new/complicating medical conditions, acute illness, and/or relapse. Some patients stay on the same dose for months or even years, but most dosages will require intermittent adjustment.
This is also the period during which the patient focuses on addressing the root causes of their addiction, treating any co-occurring disorders that may be present, and making the lifestyle changes that accompany and support a sober lifestyle.
The Tapering Phase: The Choice is Different for Everyone
Tapering means the gradual reduction of the methadone dosage until the patient is completely free of the medication. Some patients stay on methadone for many years, while others have an urgent desire to move through the phases of methadone treatment as quickly as possible. The “to taper or not to taper” discussion involves intense and passionate debate on both sides.
Some people believe an individual is not sober if they’re on methadone – click here to read our post on this subject. Others point out the fact that evidence shows people who decide to taper off methadone quickly are at higher risk of relapse and even overdose. They argue time-in-treatment almost always equals a higher rate of treatment success. While very few people will advocate staying on methadone forever, advocates of a long maintenance/action phase argue against rushing through the phases of methadone treatment, particularly if the reasons for moving quickly through the phases are related to stigma around MAT.
With all that said, best practices indicate that tapering should always be initiated by the patient, not the physician, therapist, or counselor. Any methadone taper must follow a careful tapering plan, which should include all of the following:
- Total length of time for the taper
- Rate of dose reduction
- Psychosocial support during the taper
- A contingency plan if the patient wants to stop the taper
In addition, any decision to taper should include an aftercare plan, similar to the type of plan a patient would receive when leaving treatment or stepping down from a residential or partial hospitalization program to an outpatient program. Aftercare plans should include ongoing professional support, ongoing social support, and an ongoing plan to continue lifestyle choices that support long-term sobriety and reduce the chances of relapse.
Do People Use Methadone to Get High?
You may have missed it: the primary reason people do not – or, if they participate in a legally operating methadone program – cannot use methadone to get high is a direct result of the medical criteria clinicians use to determine methadone dosage. Let’s revisit those criteria: in a nutshell, during the induction phase of a methadone program, clinicians and patients work to find a dosage that blocks withdrawal symptoms, eliminates drug cravings, blocks the euphoric action of other opioids. And, apropos of our discussion, the critical criteria:
“A dosage at which tolerance of the sedative/euphoric effects of methadone is achieved.”
The criteria also require a dose which:
“…allows the patient to conduct activities of daily living without intoxication…”
And there you have it.
People in methadone programs don’t use methadone to get high because the dosage they receive is calibrated to prevent it.
Recovering individuals who participate in methadone programs do report feeling mild euphoric and sedative effects during the first few days of treatment. However, they are neither powerful nor long lasting, and disappear completely in a short period of time. That’s because professional medical personnel make sure the dosage they take does not make them high, it give them freedom: freedom from misuse of prescription opioids, freedom from the misuse of illicit opioids, and the freedom to lead a life without the suffering and pain caused by opioid addiction.