Education Series
Number 4
April 1994
Herman Joseph, Ph.D. was part of the original team that started methadone treatment at The Rockefeller University. His research and publications have had a major influence on methadone treatment. After leaving the research team at Rockefeller University Dr. Joseph started and administered a methadone clinic for patients on probation or parole. He helped organize and was the major researcher on office based treatment. He also helped to start the KEEP Program at Riker’s Island, the first and one of the few prison based methadone programs. He is a recipient of the Dole-Nyswander Award (“The Marie”) and has been acknowledged world-wide for his contributions to methadone treatment. He has been honored with NAMA’s “Honorary Patient” title and is a member of the Advisory Board and Board of Directors.
Studies undertaken over the past two decades, primarily by Dr. Mary Jeanne
Kreek of The Rockefeller University, and corroborated by other scientists
throughout the world have established the long-term medical safety of methadone
maintenance treatment (Kreek, 1992; Kreek, 1987; Kreek, 1986; Kreek, 1978; Kreek,
1973; Kreek et al, 1972; Novick, Richman, Friedman et al, 1993). There are no
toxic effects, somatic damage or functional deficits associated with or
attributable to methadone for patients who are stabilized at appropriate doses
including those receiving over 100 mgs/day, who are not heavily abusing other
drugs (e.g., alcohol and cocaine), and who have remained in continuous treatment
for up to 18 years.
There are minimal non-toxic side effects, such as constipation, that can be
treated; excessive sweating that in most cases subsides over time; and decreased
libido and, in some males, delayed orgasm that normalizes within the first few
months of treatment or with dose adjustment (Kreek, 1978; Kreek, 1973).
Methadone does not get into or rot the bones. Patients complaining of
muscular aches are usually experiencing the initial symptoms of the abstinence
syndrome and probably need a dose adjustment. Another common myth about
methadone and health is that it rots the teeth. However, the dental problems
experienced by the majority of methadone patients is a result of their years of
using heroin and poor health. Most heroin addicts do not make visits to their
dentist every 6 months as one should and eventually the lack of care will catch
up with them. No other medication has received the scrutiny and evaluations that
methadone has which continue up to this day. The major impact of methadone
treatment on the health of addicts is that it brings them from poor to good
health (Novick, Joseph & Croxson et al, 1990).
The pharmacology of methadone, a long acting synthetic opiate of 24 to 36
hours, at adequate doses results in a daily steady state of blood plasma levels,
as compared to the interrupted on-off effects of short acting narcotics such as
heroin. Heroin, a short acting opiate of four to six hours, can produce a
deranged physiology impairing the endocrine and immune systems, gastrointestinal
functioning, reproduction, homeostasis and the general biology (Dole, 1988;
Himmelsbach, 1968; Martin, Wilker & Eades, 1963). The steady state of blood
plasma levels produced by an adequate daily dose of methadone normalizes the
deranged physiological functioning of the endocrine and immune systems induced
by heroin addiction (Dole, 1988).
Immune Functioning and Methadone
Many physicians or medical professionals incorrectly believe that methadone
inhibits the immune system and functioning. While this is true of all opioids,
and especially the short acting opiates it is not true of methadone. And in
fact, methadone is the only opioid that does not inhibit the immune system or
functioning. This is an important characteristic of methadone when considering
its impact on HIV+ methadone patients. But methadone does not only not inhibit
the immune system–it restores immune functioning.
The potential for normalization of endocrine and immune functioning is
especially crucial when treating HIV positive methadone patients. The evidence
of immune restoration from HIV negative methadone patients hints that there may
be a partial restoration of immune functioning for HIV positive methadone
patients (Kreek, 1988). While this is not proven, there are many other
advantages for HIV positive heroin users to be placed and maintained on
methadone.
In Switzerland a three-year prospective study followed a group of
HIV-infected methadone maintenance patients and a contrast group of HIV-infected
heroin users who did not enter methadone maintenance treatment (Weber,
Ledergerber, Opravil & Luthy, 1990). The results showed that a significantly
lower proportion ofmethadone maintenance patients progressed to AIDS as compared
with the untreated heroin users, 24 percent versus 41 percent, almost a-2 fold
increase within the period of the study.
Methadone when prescribed as a maintenance medication functions as a
normalizer for a deranged physiology and not as a mood altering narcotic
substitute (Dole, Nyswander & Kreek, 1966; Joseph & Dole, 1970).
Methadone maintenance, is therefore corrective but not curative.
Illicit Heroin Use and Immune Function
The continued use of heroin impacts negatively on the health of the user in
many ways. Certainly, a primary effect is the unstable life of the heroin addict
who does not eat properly or sleep normal. However, it must be emphasized that
even the piercing of the skin, as during injection will effect the immune
system. In addition the act of injecting illicit drugs are dirty and will
adversely impact on the immune system. Injecting pills is no better because they
contain buffers to hold the pill together and dies to color the pill–neither
should be injected. Only sterile water should be used which can be purchased in
a large drug store or medical Supply store. Tap water contains bacteria which
will also impact on the immune system and boiling water for short periods will
not completely sterilize the water. If you cannot get sterile water then you
could use distilled water which can be purchased at a drug store or boil tap
water for a full 15 minutes. However, injecting will weaken the immune system
and even if one only injects once in awhile each injection will begin to impact
negatively on the immune system.
The Potential Mandate of Methadone Programs on HIV Infection
Methadone programs are placed in a unique position to monitor HIV and other
infectious diseases and provide clinical prevention and intervention. For
example, AZT can be administered as well as medications for drug-resistant TB.
Most importantly, clinics can offer AIDS prevention, counseling and referrals
for services that exist in the community. Special methadone clinics and programs
can be developed that serve patients infected with HIV (e.g., St. Claire’s MMTP,
Beth Israel AIDS program on 125th Street). Unfortunately, most programs do not
have the funding to provide these services to their patients and it is up to us
to let our legislators know that these services are not only necessary in
methadone programs, but it would be more efficacious to the health care system
for methadone patients to be treated for conditions other than their addiction
in methadone programs.
References
Dole, V.P. Implications of methadone maintenance for theories of narcotic
addiction. Journal of the American Medical Association 1988 (November 25)
260(20): 3025-3029.
Dole, V.P., Nyswander, M.E. and Kreek, M.J. Narcotic blockade. Archives of
Internal Medicine 1966 (October) 118:304-309.
Himmelsbach, C. Clinical studies of morphine addictions. Nathan B. Eddy
Memorial Award Lecture. In: Harris, L.S. (ed), Proceedings of the 49th Annual
Scientific Meeting of the Committee on Problems of Drug Dependence. National
Institute on Drug Abuse, Research Monograph Series 81. Rockville: U.S. Dept. of
Health and Human Services, 1968.
Kreek, M.J. The addict as patient. In: Lowenson, J.H.; Ruiz, P.; Millman, R.B.
and Langrod, J.G. (eds), Substance Abuse A Comprehensive Textbook. Baltimore:
Williams and Wilkins, 1992.
Kreek, M.J. Summary of Presentation at 1988 meeting of the Committee for the
Problems of Drug Dependence. NIDA Notes 1988 Fall: 12, 25.
Kreek, M.J. Multiple drug abuse patterns and medical consequences. In:
Meltzer, H.Y. (ed), Psychopharmacology: The Third Generation of Progress
(Chapter 172), p 1597-1604. New York: Raven Press, 1987.
Kreek, M.J. Tolerance and dependence: Implications for the pharmacological
treatment of addiction. In: Harris, L.S. (ed), Problems of Drug Dependence.
Proceedings o the 48th Scientific Meeting of the Committee of the Problems of
Drug Dependence, 1986. DHHS No. (ADM)87-1508. Rockville, MD: National Institute
on Drug Abuse.
Kreek, M.J. Medical complications in methadone patients. Annals of the New
York Academy of Sciences 1978 311: 110-134.
Kreek, M.J. Medical safety and side effects of methadone in tolerant
individuals. Journal of the American Medical Association 1973 (February 5)
223(6): 665-668.
Kreek, M.J.; Dodes, L.; Kane, S.; Knobler, J. and Martin, R. Long-term
methadone maintenance therapy: Effects on liver function. Annals of Internal
Medicine 1972 (October) 77(4): 598-602.
Hartel, D.; Selwyn, P.A.; Schoenbaum, E.E. et al. Methadone maintenance
treatment and reduced risk of AIDS and AID-specific mortality in intravenous
drug users. No. 8546. Stockholm, Sweden: IV International Conference on AIDS,
1988.
Joseph, H. and Dole, V.P. Methadone patients on probation and parole. Federal
Probation 1970 June: 42-48.
Martin, W.R.; Wilker, A.; Eades, C.G. et al. Tolerance and physical
dependence on morphine in rats. Psychopharmacology 1963 4: 247-260.
Novick, D.M.; Joseph, H.; Croxson, T.S. et al. Absence of antibody to human
immunodeficiency virus in long-term, socially rehabilitated methadone
maintenance patients. Archives of Internal Medicine 1990 (January) 150: 97-99.
Novick, D.M.; Richman, B.L.; Friedman, J.M.; Friedman, J.E.; Fried, C.;
Wilson, J.P.; Townley, A. and Kreek, M.J. The medical status of methadone
maintenance patients in treatment for 11-18 years. Drug and Alcohol Dependence
1993 33: 235-245.
Weber, R.; Ledergerber, B.; Opravil, M. and Luthy, R. Cessation of
intravenous drug use reduces progression of HIV infection in HIV+ drug users.
Presented at the VI International Conference on AIDS. San Francisco: 1990.
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