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Issue 7 February 2004
A national newsletter on substance misuse management in primary care
Methadone maintenance prescribing
- how to get the best results
Dr Jenny Keen, Clinical Director of the Primary Care Clinic for Drug Dependence in Sheffield, and Clinical Research
Fellow at the Institute of General Practice and Primary Care at the University of Sheffield
When we consider the practical use of the evidence on of methadone. The Clinical Guidelines (11) suggest that between
methadone maintenance we must be clear about exactly what we 60 and 120 mg of methadone daily would encompass the
are trying to achieve. Ward et al (1) make the point that “…it is majority of doses required by patients on methadone
unfortunate that the success of methadone maintenance maintenance treatment but there may well be individuals who
treatment continues to be judged by what happens when it is require considerably more or less than this.
discontinued”. The primary aim of methadone maintenance
treatment is not to produce abstinence, and indeed there is no
In addition to retention in treatment and adequate dosages, it
evidence that any treatment can reliably produce this outcome in
has been shown that a sufficient duration of treatment is
the long-term. The evidence for methadone maintenance
important and that harm reduction outcomes are lost if
treatment is about improving quality of life whilst the patient is
detoxification is attempted before patients are ready (12).
actually in treatment and not necessarily when treatment is
In summary, therefore, patients should receive treatment which
discontinued, although there is no evidence that methadone
is not time limited, with no arbitrary upper limit on dosages
maintenance treatment actually increases the length of opiate
and where any move towards abstinence is driven by the
dependence (2). The outcomes that we can expect to achieve
patient, if best outcomes are to be achieved. The goal should
with methadone maintenance are therefore about in-treatment
be to provide good maintenance rather than maintenance that
harm reduction.
is compromised by the goal of abstinence.
Harm reduction outcomes
Factors associated with poor outcomes
Success in reducing drug-related harm has been shown since the
earliest studies of methadone maintenance treatment and across
Methadone programmes which tend to produce poorer harm
a very wide range of settings, services and clinical backgrounds
reduction outcomes are those which offer time-limited
(1,2,3,4,5). Findings have held good even in relatively small
treatment, dosages which are inadequate or which are reduced
studies because in general the effect size of the intervention is
before the patient wishes to do so, and those which focus on
so large. Across the board, studies have found very large
administrative processes and keeping control rather than on a
reductions in illicit drug use, major improvements in physical and
supportive and empathic approach (1,13). Low quality medical
mental health, better social adjustment and markedly less
and psychosocial services, where staff are poorly trained or have
involvement in criminal activity when patients are treated with
negative attitudes towards drug users, and programmes not
methadone maintenance. It is likely that the spread of blood-
oriented towards social rehabilitation, also seem to produce
borne viruses may also be reduced by this intervention.
poorer outcomes.
Methadone maintenance treatment also has a major impact on Selecting patients for methadone maintenance
reducing heroin-related deaths (6). Once again, however, it is
Programme variables appear to be far more significant in
important to emphasise that these are in-treatment outcomes
affecting outcomes than patient variables according to the
and there is no good evidence to suggest that they persist after
available evidence. Poor prognostic indicators for patients at
treatment has discontinued.
entry include poor mental health, poly-drug use and diversion of
How to optimise outcomes
prescribed medication. On the other hand these are the sorts of
problems that over time may well be alleviated by the very
The key to optimising outcomes seems to be to focus on the goal
treatment from which we might otherwise seek to exclude these
of maintenance as acceptable in its own right, rather than
individuals. For this reason the leading reviewers in the field
treating it merely as a stepping-stone to abstinence. With this in
(1,3) tend to conclude that, within very broad parameters, the
mind, retaining patients in treatment takes on a high level of
selection of some patients for methadone maintenance
importance, and a number of studies have associated successful
treatment and exclusion of others on the basis of prognostic
outcomes with services that succeed in retaining patients for
indicators are probably unjustified.
longer periods (4,7). Retention in treatment is linked with
prescribing adequate dosages of methadone (8), and in fact a Paradoxically, those patients most likely to die from heroin-
prescription of adequate dosages has been shown time and again related causes are untreated, older injecting drug users, who may
to be a key factor in producing good harm reduction outcomes have been using opiates for many years alongside a number of
(1,2,3,9). Given the enormous variation in individual rates of other drugs and who may have complex psychosocial needs.
metabolism of methadone (10), patients may well be the best These patients, who may be low waiting list priority compared
judge of what dose of methadone is required, although titration with younger users seeking detoxification, may be the ones for
should always take place within a robust clinical governance whom harm reduction, especially in terms of heroin mortality,
framework that includes the option of supervised consumption may be the most marked when they enter treatment (6,14).
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