Methadone: Treatment, Withdrawal, Abuse, Uses, Side Effects & Dose

What is Methadone?

Methadone is a prescription medication that seems to have received more attention in recent years. According to experts writing for the Western Journal of Medicine, methadone belongs to the opiate class of drugs, and it is comparable to morphine. This prescription medication does have legitimate medical uses and is safe and effective when people use it as a doctor prescribes it, but for some people, it may become addictive and dangerous.

Medical Uses of Methadone

What is methadone used for? One of the most common uses of methadone is for the long-term treatment of addiction to opiates like heroin. Methadone is used as a maintenance medication to help people remain abstinent from heroin and other opiates. It promotes abstinence because it has long-lasting effects and stops the unpleasant symptoms of opiate withdrawal; methadone also reduces heroin cravings and stops people from feeling high if they do take heroin, per the authors writing for the Western Journal of Medicine.

When used as a treatment for heroin addiction, methadone has the following benefits:

• It reduces the illegal use of heroin.
• It decreases the likelihood of diseases like HIV and hepatitis from injecting drugs.
• It lowers the number of deaths associated with heroin use.
• It decreases criminal behavior.

Numerous studies have shown that methadone is effective for preventing heroin-related deaths. In fact, researchers writing for a 2017 publication of the British Medical Journal analyzed the results of 19 different studies and found that methadone use significantly reduces overdose death rates among people in treatment for opiate addiction. Methadone can quite literally save lives for people living with a heroin addiction.

Aside from being used as a maintenance drug to promote abstinence from heroin, methadone may be prescribed in detox programs for people who are withdrawing from heroin. As the body rids itself of heroin, people may experience uncomfortable withdrawal side effects, such as nausea, vomiting, chills, and flu-like symptoms. Methadone can reduce the severity of these symptoms and make people more comfortable as they detox from heroin. According to the authors of the report in the Western Journal of Medicine, the goal of methadone detox is to gradually taper methadone doses until a person no longer needs the drug. One caveat to this process is that people may be at high risk of relapsing to heroin use after methadone is discontinued, so it may be necessary for some patients to taper methadone use over a period of several months.

While methadone is commonly prescribed in detox and treatment settings for heroin abuse, this is not the only use of this drug. Another common medical purpose for methadone is for the treatment of ongoing severe pain, as it is comparable in effectiveness to other opiate pain relievers like morphine.

In summary, the most common uses of methadone are as follows:

• Use in heroin detox programs
• As a maintenance medication for people in treatment for opiate addiction
• To relieve chronic pain

Methadone Side Effects

While methadone is effective for treating pain and heroin addiction, it does come with some side effects. According to the U.S. National Library of Medicine, common side effects of methadone include:

• Sleep Problems
• Vision Issues
• Mood Swings
• Dry  Mouth
• Headaches
• Weight Gain
• Stomach Pain

In rare cases, side effects may be more severe and include breathing difficulties, extreme drowsiness, seizures, swelling of the face and throat, hallucinations, racing heart, confusion, dizziness, coordination problems, hives, and nausea or vomiting. While these side effects seem concerning, there is evidence that most people can safely take prescribed methadone doses without severe consequences. For instance, a research report in The Clinical Journal of Pain found that side effects associated with methadone tend to be minor.

While methadone side effects are usually minor, some potential effects of methadone warrant caution and monitoring. For example, people may find the weight gain associated with methadone use to be particularly troubling. A 2016 study in the journal Substance Abuse found that there was a significant increase in body mass index among people who started taking methadone. The study also showed that weight gain was linked to poor diet habits and cravings for sweets during methadone treatment, suggesting that those in recovery for heroin addiction may simply develop some poor eating habits while taking methadone.

Another potential side effect that warrants monitoring is the risk of sleep-disordered breathing while taking methadone. A study in a 2008 publication of Pain Medicine found that among a sample of patients taking opiates for pain relief, 75 percent had sleep apnea, and daily methadone doses were directly related to this medical condition. Patients who have other risk factors for sleep apnea or who have a history of sleep-disordered breathing should be aware of this potential side effect and utilize caution when taking methadone.

Methadone Dose

The prescribed dose of methadone will vary based upon a patient’s unique needs and the purpose for which he or she is taking methadone. According to the Western Journal of Medicine, patients who are in a detox program with methadone typically begin by taking 10 to 20 mg per day, and prescribers will increase the dose by 10 mg increments as needed until a patient is able to cope with the withdrawal symptoms. Most patients are comfortable with a daily dosage of 40 mg of methadone while undergoing opiate withdrawal. A patient who is taking methadone only for detox purposes will typically take a dose of around 40 mg for 2 to 3 days, and then a slow tapering of the daily dose will begin. The specific dose and tapering regimen is unique to each patient, and some may require higher doses.

For patients taking methadone on an ongoing basis for maintenance therapy, higher doses are typically necessary. The research shows that a daily dose of 40 mg of methadone may not be sufficient to manage opiate cravings. In fact, doses of up to 80 to 100 mg of methadone per day seem to be more effective for promoting abstinence from heroin.

Methadone dosages are different for those taking this medication for chronic pain. For instance, a dose of 2.5 to 10 mg every three to four hours is typical for severe pain, and patients who are suffering from chronic pain related to a terminal illness may take doses of 5 to 20 mg every 6 to 8 hours throughout the day.

Experts do caution that it is important that doses not be too high when a patient is beginning methadone treatment, because high doses can become toxic to a patient who is initiating treatment with this drug. The doses discussed here are what are typical once a patient is stabilized on methadone, but doctors typically begin with lower doses and increase them as necessary until a patient is receiving the optimum benefit from methadone.

Methadone Treatment Protocols for Opiate Addiction

Methadone can be used to treat chronic pain, but this drug is most popular for its role in treating opiate addiction, and experts have developed specific treatment protocols to ensure best practices when administering this medication. According to stipulations from the Substance Abuse and Mental Health Services Administration (SAMHSA), a person should meet the criteria for an opiate use disorder, which is the clinical term for an addiction to heroin or other opiates, in order to be eligible for methadone treatment. SAMHSA also states that a person should have a history of one year or more of opiate addiction before beginning methadone treatment, so those with a more mild form of opiate use disorder may not be eligible to receive methadone. Finally, SAMHSA recommends that physicians begin with a low daily dose and slowly increase it, while completing daily dosage monitoring, over a period of a few days to a few weeks.

In addition to starting slowly and ensuring that people meet specific criteria for a methadone prescription, it is also important to understand that doctors will determine the optimal methadone dose for each unique person, so daily doses can vary from person-to-person. That means that two people who are in methadone treatment for opiate addiction may receive different daily doses based upon their individual needs.

Prior to beginning treatment, a physician will likely complete an assessment like the Clinical Opioid Withdrawal Scale (COWS), which provides evidence that a person has a tolerance for opiates and can safely begin methadone. A doctor will also complete other medical tests, such as drug testing and an HIV/AIDS test.

Another critical factor in methadone treatment for opiate addiction is that patients legally must receive their methadone from a certified Opiate Treatment Program (OTP). One requirement of such treatment programs is that they mandate that patients receiving methadone also complete counseling services for opiate addiction.

One feature of OTPs that provide methadone is that they usually require patients to travel to a clinic daily, especially in the beginning stages of treatment. Daily appointments allow medical staff to ensure that patients are adhering to their prescribed dosages and responding appropriately to the medication. During these appointments, medical staff will observe as patients take their methadone doses. The law does allow for one take-home dose of methadone per week, given that clinics typically close during the weekends. Within the first 90 days of methadone use, patients who make satisfactory progress may earn the privilege of having one extra take-home dose each week, but all other doses are administered in the clinic.

On the very first day of methadone treatment, medical staff will observe a patient for up to four hours after taking methadone to ensure that there are no adverse effects. A patient who experiences reduced withdrawal symptoms with the first dose will be sent home, so long as there are no serious side effects, like excessive sedation or breathing difficulties. A patient who responds well to the initial dose will return the following day to continue methadone treatment. Those who do not experience a reduction in withdrawal symptoms will remain at the clinic for an additional dose and continued medical monitoring. In cases of overdose, which are considerably rare when beginning methadone treatment, medical staff will call 9-11 as needed.

As a patient progresses through the first few weeks of methadone treatment, a doctor will continue to increase medication dosages every 3 to 5 days. Around week 5, a patient will likely be stable and be able to maintain his or her daily methadone dose. Over time, people who are compliant with treatment and who remain free from illegal drugs may be able to earn additional take-home dosages of methadone, so they do not have to report to a clinic every day. State regulations regarding take-home doses can vary.

Methadone vs. Other Drugs for Opiate Withdrawal and Addiction

Suboxone vs Methadone

While methadone is commonly used to treat opiate addiction, it is not the only drug available for this purpose. Buprenorphine is another drug that doctors commonly prescribe to treat opiate addiction, and researchers have carried out numerous studies to determine whether methadone or buprenorphine is superior. A 2014 report in the Cochrane Database of Systematic Reviews analyzed the results of 31 different studies and determined that buprenorphine is an effective treatment for heroin addiction, as it keeps people in treatment and reduces illegal opiate use. That being said, buprenorphine is not as effective as methadone is when prescribed in lower doses or according to flexible rather than fixed dosing regimens. Methadone seems to be better than buprenorphine for keeping people in treatment.

On the other hand, buprenorphine may be safer than methadone is.  For example, a 2009 study in Drug and Alcohol Dependence found that the overdose death rate was significantly lower for buprenorphine than for methadone. About half of the methadone deaths recorded in the study were among people who were in treatment, whereas none of those who died from buprenorphine were receiving treatment at the time of death.

Some researchers have also compared methadone to tramadol, a less powerful opiate. A 2012 study in the Journal of Addictive Diseases found that tramadol was just as effective as methadone was for treating opiate withdrawal, and side effects with tramadol tended to be less severe than with methadone. Tramadol is an alternative medication for the treatment of opiate addiction.

Considerations for Pregnant Women

Another reason that people may consider alternative medications to methadone is that this drug can be potentially harmful to a developing baby. Women who take methadone during pregnancy may give birth to babies with neonatal abstinence syndrome (NAS), a condition in which a baby withdraws from a drug that a mother took while pregnant. Some babies who are born with this condition may require treatment in the neonatal intensive care unit after birth. A 2009 study published in BJOG: An International Journal of Obstetrics and Gynaecology found that nearly half of babies born to women who took methadone during pregnancy had NAS that required medical treatment. The risk of needing medical treatment was lower when mothers chose to breastfeed their babies, so this may be a protective factor.

Additional research has compared methadone to buprenorphine to assess the effects on developing babies. A 2014 study in the American Journal of Epidemiology suggests that babies born to women who took buprenorphine instead of methadone while pregnant had better outcomes. For example, babies born to mothers who took buprenorphine were less likely to require treatment for NAS, and they spent less time in the hospital after birth. Those who did need treatment required lower doses of medication. Finally, babies exposed to buprenorphine were born at an older gestational age and tended to be larger when compared to those whose mothers took methadone throughout pregnancy. Expecting mothers who are using medications to treat opiate addiction should be mindful of the risks to their unborn babies, while also recognizing that a medication prescribed and monitored by a doctor is much safer for a developing baby than illicit heroin is.

Methadone Abuse Potential

While methadone is a therapeutic drug with legitimate purposes for treating both pain and heroin addiction, some people may abuse methadone as well. The Drug Enforcement Administration (DEA) labels methadone as a Schedule II Controlled Substance, meaning that abuse is likely and can cause significant symptoms of physical and psychological dependence. The DEA also reports that people who abuse methadone can develop a tolerance to the drug. This means that they will need more and more methadone to achieve the same effects.

Since methadone can be abused, people have developed “street names” for the drug in an attempt to keep their drug use discreet or secret. The street names for methadone include:

• Chocolate Chip Cookies
• Fizzies
• Maria
• Pastora
• Salvia
• Amidone
• Wafer

Prevalence of Methadone Abuse

Methadone abuse does seem to be increasing in recent years. According to data from the American Association of Poison Control Centers, there has been an uptick in methadone exposures and deaths since 2008. Research also shows an increase in emergency room visits related to methadone since 2004, and just over three-fourths of these visits are for non-medical use of methadone, such as abusing a prescription or taking a prescription belonging to someone else. Beyond the increase in deaths and hospital visits for methadone, there has been a slight elevation in the number of people seeking treatment for methadone abuse, according to a 2013 report in The American Journal on Addictions.

In addition to the increase in the prevalence of methadone abuse, it is noted that the data shows that people tend to abuse methadone in combination with alcohol and/or other drugs, which can lead to complications. Even prescribed drugs can be dangerous when combined with methadone, as research shows that a type of prescription anxiety medications called benzodiazepines are commonly involved in methadone-related deaths and poisonings, per the report in The American Journal on Addictions.

Methadone Overdose Risks

In addition to the fact that methadone abuse seems to be increasing, there is a concern of overdose when people abuse this drug. According to a doctor writing for The Assessment and Treatment of Addiction, overdose is rather likely when people use methadone to treat pain. For example, during one year, methadone comprised 2 percent of opiate prescriptions in the United States but resulted in 30 percent of the deaths from prescription opiate overdoses. The risk of overdose is higher among people who mix methadone with alcohol or other sedatives like benzodiazepines.

Methadone Half-Life

In addition, methadone has a long half-life, meaning it stays in the body for a long period of time. It is for this reason that overdose can occur when a person first begins taking methadone, as the drug can quickly build up in the body. Experts therefore recommend that doses start low and slowly increase as a doctor monitors them to ensure safety.

Methadone has a long half-life, which can cause an overdose if initial doses are too high; for the same reason, overdose risk is also higher among people who take more methadone than is prescribed or who buy the drug illegally off the streets. Taking more methadone than a doctor prescribes can cause a quick buildup of the drug, and a street drug dealer is not qualified to determine if a particular methadone dose is suitable or safe for an individual person. Overdose risk is therefore a legitimate concern among people who abuse methadone.

According to the DEA, someone who is suffering from a methadone overdose is likely to have slow, shallow breathing, and his or her lips and fingernails may turn blue. Other methadone overdose symptoms include the following:

• Clammy Skin
• Weak Heart Beat
• Stomach Spasms
• Convulsions
• Coma, and eventually death

Methadone overdoses can be fatal, so medical treatment is necessary. A study in The American Journal of Emergency Medicine analyzed 44 methadone overdose cases in adults. The majority of patients displayed signs of opiate toxicity and received treatment with naloxone. Patients tended to show signs of overdoses within about 3 hours of taking methadone, and all recovered within 24 hours.

Naloxone is typically the drug of choice for treating methadone and other opiate overdoses. According to the National Institute on Drug Abuse, this drug quickly reverses opiate overdoses and returns breathing to normal after a person suffers from an overdose. Quick administration of naloxone can be life saving for someone who is overdosing on methadone.