Dispelling Myths About Medication for Opioid Use Disorder (MOUD)

There is a long history of inaccurate information regarding the dangers and problems with opioid treatment. Below, are some of the most common misconceptions about methadone and buprenorphine, followed by relevant, accurate information. 
                                

"Methadone and buprenorphine don’t help patients, they simply substitute one drug for another."  

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Although methadone and buprenorphine occupy the same receptors in the brain that heroin and prescription opioids do, they occupy them much more slowly and stay much longer. It is the rapidity of occupation by heroin that leads to the “high” or “rush” that the person who uses heroin craves, and it is the speed at which they leave the receptor that causes craving. Adequate doses of methadone or buprenorphine also push the patient’s tolerance up to a level at which a high cannot be felt from an easily obtainable dose of heroin. This leads to a decrease, and eventually (at adequate medication levels) a cessation of drug craving and seeking. Because patients maintained on methadone or buprenorphine are not medication free does not mean they are not in recovery and are not being helped.

 

Opioid use can be a life threatening condition. For example, persons who inject heroin are using a drug of unknown potency, diluted with unknown chemicals. The equipment people use to inject the substance may be infected with HIV or hepatitis. They have no medical or psychological assistance to address physical, psychological, or other critical problems. Short acting opioids, such as heroin, produce tolerance and must be used in increasing amounts. They can only be obtained through illicit markets, and the high cost is often the impetus for involvement in crime to pay for the habit. Heroin and the activities associated with its use keep the individual heavily involved in the drug lifestyle and surrounded by drug dealers or other drug users virtually 24 hours per day. This makes it difficult for users to maintain employment or any semblance of family life. While taking methadone or buprenorphine, a patient can be socially rehabilitated (or habilitated) for the first time.  In addition, almost all of the hormonal and neurological abnormalities caused by chronic heroin use are normalized off heroin and on these medications. 
                               
Methadone and buprenorphine are controlled substances, produced and distributed under close supervision and quality controls. They are taken orally and sublingually, respectively, and do not require the use of needles, reducing the risk of HIV and other infections. The long half life of both methadone and buprenorphine allows them to be administered only once a day. These relatively few doses of medication eliminate the craving for heroin or other opioids for most patients, which allows them to participate in employment, school, recreational, and therapy activities. Methadone and buprenorphine treatment is provided in a setting where medical and counseling services are available to patients, promoting better health care and improved psychosocial function. Therefore, there are important and life-saving benefits to patients in treatment.

"Methadone and buprenorphine keep you high all the time." 

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When the dose is adjusted adequately, patients maintained on methadone or buprenorphine should function without sedation or intoxication. Once stabilized, the patient may experience a sense of well being at the onset of medication, but they quickly feel “normal”. They do not get high and, thus, avoid the 4 hour cycles of intoxication and withdrawal that accompany the use of short acting opioids, such as heroin.

 

"Patients on methadone and buprenorphine keep using drugs and alcohol." 

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Just as insulin is not a cure for diabetes, methadone and buprenorphine are not cures for opioid use disorder, but rather medications that reduce symptoms associated with withdrawal and craving. Moreover, methadone does not treat either psychostimulant (cocaine or methamphetamine) use or alcoholism, although studies have shown that a majority of patients on methadone substantially reduce their overall use of all drugs, including alcohol. For now, however, it is clear that treatment results in a very substantial reduction in illicit drug use, but it does not eliminate all use of drugs and alcohol. 

 

"Patients on low doses of medication are doing better in treatment than those on high doses." 

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There has been extensive philosophical debate over the relative value of low dose versus high dose methadone programs and what constitutes the "best" dose. Some so called low dose programs maintain a ceiling dose of 40 milligrams while other programs allow doses up to 180 milligrams. Outcome studies have indicated that patients maintained in programs with a mean dose of at least 60 milligrams function better, use drugs less, and stay in treatment longer than those in programs with lower dosing practices. It is the New Life Clinic philosophy to have the physician adjust the dose of methadone or buprenorphine to meet the needs of each patient and to maximize the patient’s ability to discontinue heroin or prescription opioid misuse and remain in treatment. At times we will use blood levels to determine if a patient is receiving an adequate dose. As this procedure becomes more perfected, however, the most beneficial dose levels may be determined by using a combination of self-report and urine test results. Until an adequate blocking dose of medication is attained, it is not unusual for a patient to continue to crave, seek and/or use other opioids.

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Thus, as long as opioids continue to turn up in the urine, the medical staff will continue to adjust the medication until the dose is adequate.  

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Note: buprenorphine has a “ceiling” effect (generally at 32mg) in regards to its additive effect, therefore, most individuals will reach a stabilizing dose at 32mg or below.  

 

"Methadone and buprenorphine are harder to kick than heroin."

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Because methadone and buprenorphine have a longer half life than heroin, withdrawal from methadone or buprenorphine may take longer than withdrawal from heroin. Some people report that the symptoms of withdrawal from the medications to be more severe than those of heroin withdrawal, with methadone generally reported as longer in duration than buprenorphine. However, if the patient follows a medically supervised tapering schedule and post medication withdrawal management program, they can withstand the withdrawal process with less extreme discomfort.  Medication should not be evaluated by “how easy it is to taper off of”, but rather how effective it is while being medicated.

 

"After patients go off methadone or buprenorphine, they go back to using." 

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The value of methadone and buprenorphine should be viewed as similar to the value of other medications taken for chronic medical conditions. For example, many people take medications to reduce their blood pressure and they are effective. Most people who use them find that their blood pressure goes up when the medications are stopped. Although these medications do not cure high blood pressure, they control it during the time they are used.  The same can be said for methadone and buprenorphine. They are not a cure. Many patients on these medications are able to make changes in their lives and build support systems that help them stay sober when they complete their treatment. However, this post medication success occurs only when there is a clear plan for continuing care; otherwise, a return to drug use may occur and individuals will need to be readmitted into treatment. In short, heroin addiction is a chronic, relapsing disorder, and methadone and buprenorphine are useful tools for controlling it.  

 

"Pregnant individuals should not take methadone or methadone, because the baby will be born addicted."

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Individuals who use heroin and are pregnant and subsequently treated with methadone or buprenorphine can deliver healthy babies. Babies born to individuals on methadone or buprenorphine do often experience some withdrawal symptoms during the first several days after birth, but the symptoms are routinely treated by the baby's pediatrician and do not result in long term damage. Babies born to individuals on methadone or buprenorphine also tend to have a slightly lower birth weight than babies of non-drug using, control individuals. What is most important is how these babies compare with babies exposed to opioids and not with babies with no opioid or methadone/buprenorphine exposure. Comparison studies have demonstrated significant benefits from methadone and/or buprenorphine treatment during pregnancy.
                                
Individuals on methadone or buprenorphine should receive adequate prenatal care, including nutritional supplements and information, and parenting classes. Evidence supports the use of methadone and/or buprenorphine with heroin addicted individuals to reduce the risk of miscarriage, increase birth weight, reduce infection and HIV risk to the fetus, thereby, producing a healthier baby. Dose levels for the mother should be adjusted by the physician to a level that best helps her to abstain from street drugs. There is no single best dose for a pregnant individuals.

 

"Buprenorphine is a cure for opioid dependency and is better than methadone."

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Buprenorphine is a partial agonist and thus has different qualities than methadone, a full agonist. Although some patients do report it is “easier” to withdraw from buprenorphine than from methadone, this does not necessarily make buprenorphine a “better” medication, nor by any means a cure for opioid dependency. It is merely another option. As mentioned previously, there is no cure for opioid dependency.

 

Substance use disorder is a chronic, relapsing disease. A medication’s effectiveness should be determined by how well one performs while using it, not by how “easy it is to get off of it.” Remember, both medications are instruments to aid you in your recovery and may be needed for an indefinite length of time.

 

Research shows that, in general, the longer individuals remain on methadone or buprenorphine, the more successful they are in maintaining abstinence, acquiring employment, reducing/ceasing criminal activity, addressing their healthcare issues and so forth. Therefore, choosing one medication (buprenorphine) over the other (methadone) based solely upon how it will feel when the medication is stopped, is not the most appropriate way to look at recovery. We encourage individuals to discuss the advantages and disadvantages of BOTH medications with the physician in order to see which medication may work best for that particular person.