3rd November 2020 • Sticky Post

Opioid Replacement Therapy: Weighing the Costs/Benefits

 

Opioid Replacement Therapy (ORT) is a way to lessen the impact of addiction to opiates and opioids by replacing dangerous drugs like fentanyl and heroin with legal, long-acting, non-euphoric drugs such as methadone and suboxone. Advocates cite a host of benefits that can be obtained through Opioid Replacement Therapy, including reducing the risk of HIV transmission, overdoses, and crime, while helping the addicted to hold down jobs and maintain functional relationships. Opioid Replacement Therapy also theoretically keeps individuals in treatment by reducing the symptoms of withdrawal and the cravings for illicit drugs. It sounds appealing, and methadone has been a popular treatment for years. The World Health Organization has labeled it an essential medicine, and it’s used without question by health-care providers the world over (almost 50,000 kgs. of it are manufactured every year). But is ORT really the best way to treat opioid addiction?  

Methadone: Pros and Cons

Opioid replacement therapy: weighing the pros and cons

As a long-acting opioid, as well as an opioid agonist, methadone ensures that the user typically needs a single daily or bi-daily dose and that they cannot experience highs even if they use other opioid drugs. This allows those who use the substance to return their lives to some sort of normality. Since most users are obtaining a single dose every 24-48 hours in an outpatient setting, they are free to go about their daily business unencumbered from intoxication or the need to secure more drugs. Furthermore, enrollment in an opioid replacement program generally nudges the user towards meaningful interactions with the health-care system which can successfully steer them towards a more complete recovery. 

A study from Harvard University’s medical school found that approximately 25% of methadone users would successfully wean themselves from the substance over the long-term, 25% would continue using it indefinitely, and 50% would eventually return to their previous addiction. A 2009 study from the Cochrane Review concluded that methadone treatment increases the chance of successful treatment outcomes by helping to retain patients in treatment and that it decreases heroin use compared to programs that don’t offer opioid replacement therapy. The study also found that methadone didn’t actually decrease the risk of mortality or prevent criminality in a statistically significant way.

While methadone programs offer some substantial benefits to those grappling with addiction, they come with substantial side-effects and risks. Common side-effects include nausea, vomiting, sexual dysfunction, slowed breathing, and itchy skin, and there is some evidence that prolonged use can cause a number of lung and respiratory issues. Meanwhile, neuroscientists are still discovering the effects methadone use has on the brain, as experiments with rats have shown that a three-week course of methadone led to a “significant” – 70 percent – reduction of a signal molecule that supports memory and learning in the brain’s frontal lobe and hippocampus. Methadone is also a deeply addictive substance, which causes worse withdrawal symptoms than the heroin that it replaces. And the risk of overdose doesn’t go away for those using methadone. In fact, the American Center for Disease Control reports that methadone is to blame in a full third of all prescription painkiller related deaths occurring in the USA. 

Methadone has helped many addicts by acting as a first step towards recovery, offering a measure of stability in their lives, and enticing them to interact with recovery professionals. But the side-effects and risks associated with its use are deeply concerning, and there are other options available for those looking for ORT.

Naltrexone and Buprenorphine

Naltrexone and Buprenorphine

Like methadone, buprenorphine is a synthetic opioid that can reduce or curtail the symptoms of withdrawal. Suboxone, the most common variety of buprenorphine, also contains a substance called naloxone, which causes serious and deeply unpleasant side-effects if the substance is injected. It is included to reduce the potential for abuse. Suboxone was approved for use by the American Food and Drug Administration in 2002, and it has become incredibly popular. In 2013 the drug made $1.55 billion in sales, more than Adderall and Viagra combined!

Buprenorphine treatment has some significant advantages over methadone. It has less potential for abuse because of the inclusion of naloxone. It has also proven to be a safer alternative. A 6-year study conducted by researchers in England and Wales found methadone was more than 6 times more likely to cause overdose deaths than buprenorphine, with 2,366 mortalities associated with methadone use, and only 52 related to buprenorphine.

Naltrexone is another synthetic opioid that was originally intended for use in pill form. The American government concluded that it “does not produce tolerance or withdrawal. Poor treatment adherence has primarily limited the real-world effectiveness of this formulation. As a result, there is insufficient evidence that oral naltrexone is an effective treatment for opioid use disorder.” However, in 2010 an extended-release, injectable form of naltrexone was approved by the FDA. This version requires a single injection per month and has been found to be as effective as buprenorphine in reducing opioid use. However, withdrawal from opioids must be completed before this type of naltrexone is safe to use, which is a significant barrier for many addicts.

Buprenorphine and naltrexone can offer a sufferer the benefits of methadone treatment, along with reduced risk of overdose, death, and abuse. However, like methadone, they are imperfect solutions that can help addicts to manage their affliction and lead them into treatment but also create a new dependence that can take years to break free of.

Effective Alternatives

Opioid Replacement therapy: weighing the costs and benefits

You may already know about Iboga’s ability to treat withdrawal symptoms and substance cravings, as well as its remarkable restorative effects on the brain. If you don’t, you may want to read this post on iboga’s effectiveness in treating opioid addiction. In addition to its clinical benefits, the substance induces an ego-free, reflective state that can also help addicts deal with past trauma and certain mental health issues.

Unlike methadone, iboga isn’t habit-forming and is extremely unlikely to be abused. There is no evidence that it is physiologically or psychologically addictive. While systematic, controlled clinical trials in the US and Europe have yet to be conducted (mainly because the substance is classified as a Schedule I drug), there are countless testimonials from people who credit iboga with saving their lives and allowing them to escape from addiction.

Iboga use is not without risk. It can exacerbate pre-existing cardiac conditions, and in abnormally large doses it may induce seizures. But even though it is often self-administered, or used in unsafe settings due to its murky legal status, it is still safer than methadone, causing 1 death in every 427 reported treatment episodes, compared to a 1:364 mortality rate for methadone.