Education Series
Number 5.1
February 2001 (Revised)
Joycelyn Woods has a graduate degree in neuroscience and psychopharmacology. She has published in neuroscience journals and is recognized internationally for her methadone advocacy work. She is a recipient of the “Richard Lane Methadone Advocacy Award.”
The Lack of Education
Ignorance about methadone abounds (Zweben and Sorensen, 1988). Stigma and prejudice have
kept accurate education about methadone treatment being taught in medical and
schools of higher education. The primary source of information about methadone
comes from the sensationalized media. Thus, professionals working in the
field, supportive services to methadone treatment, law enforcement, health
professionals, employers and the public know very little about methadone at
all, and what they do know is probably wrong. Even worse is the fact that they
don’t know that they don’t know. And, at the bottom of this is the
methadone patient who must bear the brunt of the prejudice and stigma and with
no where to turn to. Methadone patients read the denigrating newspaper
articles and television reports that disparage methadone maintenance treatment
and malign methadone patients — and they believe it. There is no one to
reinforce the many accomplishments of methadone patients or to celebrate the
many contributions that methadone patients make to their communities.
Methadone patients do it alone, frightened and in spite of the opposition
against them.
Academia
Professionals working in the field receive very little, or no training at all about the very
medication that they will be administering. The only training that physicians
receive while in medical school consists of about one hour spent on the topic
of addiction, which includes alcoholism. The disease model of opiate addiction
is not presented or discussed and therefore physicians do not see opiate
addiction as a condition under the domain of medicine. Their education
regarding methadone is usually on its use in withdrawing an individual from
opiates while its best properties, that of maintenance, are neglected.
And the few interns who do some into contact with methadone patients are usually
on the detox wards with the dysfunctional patients. They have never seen or
come into contact, at least that they know about, with the typical working
methadone patients. Knowing this it is not wonder that methadone patients are
treated so badly by the health and medical professions.
Counselors, social workers and psychologists know even less than the medical professions.
They usually receive very little education in basic science and even less
about the biology of behavior, or the functioning of the brain. Very often
their graduate training is anti-medication as ‘just a substitute.’
Thus, both medical and counseling professionals have been taught to
approach addiction as a character disorder with very little understanding
about the biology of addiction.
With such a deficiency within higher education added to the public’s
misunderstanding about addiction it is not surprising that myths about
methadone thrive. For thirty years there has been a conspiracy of silence
about methadone maintenance treatment. Accurate and scientific information
about methadone is rarely presented. The basic education about methadone
treatment that professionals receive comes from the same source that the
average citizen receives it from — the media that has distorted and
sensationalized the majority of methadone information.
Therapeutic Communities
Of course, there is an additional source in this equation of misinformation about
methadone and that from therapeutic communities. They were the first to attack
methadone because they know the initial successful outcome reports which when
compared to their outcome data would be impossible for them to achieve. They
were fearful of a loss of funding and mounted an attack against methadone
maintenance treatment almost from the very beginning. The primary impact of
these attacks had been to hard the esteem and well being of methadone
patients. Throughout methadone’s thirty year existence several therapeutic
communities have launched attacks at methadone treatment. Although today these
attacks are more subdued they remain.
Clients of drug free modalities receive a propaganda campaign against methadone which
is unfortunate since the majority will relapse to heroin use and would
probably be excellent candidates for methadone maintenance.
Many states agencies which oversee drug treatment funding are
controlled by abstinence oriented modalities. Only New York State, which has a
large methadone system that treats about one-fifth of all methadone patients
in the United States has a state agency that is supportive of methadone.
Education Empowers Methadone Patients
With such misunderstanding about methadone the only way for methadone patients to
deal with it and to insure adequate health care and supportive services is to
educate themselves. In this way methadone patients can educate others — the
providers, supportive services and health care professionals who should know
about heroin addiction and methadone treatment, but don’t. That is the
purpose of this paper and although some of the topics are very technical it is
not important that you understand every word. Do not allow the fact that this
is science to scare you off. Instead try to get just a basic understanding of
everything and keep this paper for future reference. When you must go
somewhere where you will probably have to divulge your status as a methadone
patients review this paper and then go over in your head what you will say to
the doctor, social worker or counselor.
If you present yourself as a methadone patient then you must behave as
a role model — no matter how badly they behave or mistreat you, and we all
know how difficult this can be. Your behavior should demand respect and if you
are not treated with dignity then go to their supervisor and demand that
adequate training about methadone be given to the institutions employees.
Write a letter to the president of the hospital, the director of the program,
the person in charge and demand a change in the way that methadone patients
are treated.
Griping for thirty years and expecting others to do it has done nothing
more than to make the problem worst. We must it for our dignity — to receive
the adequate health care we deserve from hospitals, clinics and physicians and
to be treated with respect from all the helping professions.
The purpose of this paper is to provide accurate information about the
pharmacology of methadone and to debunk the any myths that flourish about
methadone.
The next time you hear something “crazy” about methadone ask
that person for the scientific proof. Ask for references and publications. You
will discover that usually they have none. Myths and misinformation rely on
the “everybody knows” method of science! Challenge and question and you
cannot go wrong.
Methadone Patients as Health Consumers
Methadone patients must learn to be health care consumers when it comes to their medical care.
New medications are being placed on the market every day and many doctors may not
realize that it can effect your methadone. Pain medications are the search for one with a low addiction potential
is one class of medication that all methadone patients should ask about to
make sure that they are not getting a mixed agonist-antagonist (see Part 2,
Agonists and Antagonists; Part 3, Narcotic Antagonists and Agonist-Antagonists
Drugs). So it is up to you to ask the doctor and to make sure than none of the
medications that have been prescribed for you will interact with your
methadone. As health care consumers, methadone patients must insure that the
health care they receive is the quality that they deserve.
Where To Get Information
Pharmacological information about methadone and other psychoactive drugs can be found in The
Pharmacologists Bible, or Goodman and Gillman’s The Pharmacological Basis of
Therapeutics. Goodman and Gillman is far superior to the reference book, The
Physician’s Desk Reference (PDR) that most go to for information because it
gives not only clinical information as the PDR, but pharmacology, metabolism and
the recent research findings.
NAMA produces an Education Series and provides scientific publications. Another
source is the National Clearinghouse for Alcohol and Drug Information
(1-800-SAY-NO-TO(DRUGS)) that will do a literature search and send either a
bibliography for you to chose from or send publications directly. Sometimes the
later choice cannot be done because of the vast amount of literature. So beware
of myth-makers and “everybody knows science.” Methadone is one of the
safest and most effective procedures that I know of, yet it is constantly
denigrated by nay sayers who do not understand methadone maintenance or heroin
addiction.
Challenge the nay sayers! Ask them for proof, real science!
Basic Pharmacology
Pharmacology is the study (ology) of drugs (pharmacy). Psychopharmacology is the study of (ology)
drugs (pharmacy) that produce their effects on the mind or brain (psycho
or psyche). There are five basic classes of psycho-active drugs: 1) the opioids
(i.e., heroin and methadone), 2) the stimulants (i.e., cocaine, nicotine), 3)
the depressants (i.e., tranquilizers, antipsychotics, alcohol), 4) hallucinogens
(i.e., LSD), and 5) marijuana and hashish (Cooper, Bloom and Roth, 1991).
Most compounds, including opioids exist in two forms, one form in active and one
inactive — that are distinguished by levo or dextro preceding the compound’s
name (Goldstein, 1994). Sometimes just the first letter, l or d is used to indicate the form of the compound.
left handed = levo-methadone = l-methadone = methadone
right handed = dextro-methadone = d-methadone
Generally speaking the active form is usually the -levo form and very often levo- is
dropped from the compound’s name completely. The best way to think of these
two forms is your two hands. Both the right and left hand have the same
structures (i.e., one thumb and four fingers) but they are mirror images of one
another. And like hands, the levo and dextro form are very different from one
another, one active, one inactive, yet similar — the same basic three
dimensional structure.
Administration
An important factor in how a psychoactive drug exerts it effects is how it is
administered. Administration refers to the mechanisms by which drugs are
transported from the point of entry into the bloodstream. Drugs are commonly
administered in five ways: 1) orally, 2) rectally, 3) parentally (injection), 4)
the membranes of the mouth or nose, and 5) by inhalation. Each method of
administration has its advantages and disadvantages (see Table 1) (Cooper, Bloom
and Roth, 1991).
Table 1. The Routes of Administration. There are five ways that drugs
are commonly administered: 1) orally, 2) rectally, 3) parenterally
(injection), 4) the membranes of the mouth or nose, and 5) by inhalation.
From Gilman, Rail, Niles, Taylor, Goodman and Gilman’s The Pharmacological Basis of Therapeutics (1990).
After a drug is administered the next important determinant in the drugs ability to
exert its effect is how the drug is distributed throughout the body (Barchas,
Berger, Ciaranello and Elliot, 1977). Once the drug reaches the bloodstream it
is distributed throughout the body. However, it must be able to pass across
various barriers in order to reach the site of action. Only a very small portion
of the total amount of a drug in the body at any one time is in direct contact
with the specific cells that produce the pharmacological effect of the drug.
Most of the drug is found in areas of body that are remote from the drug’s site
of action. In the case of psychoactive drugs, most of the drug is to be found
outside of the brain and is therefore not directly contributing to the
psychopharmacological effect. Four types of membranes are most important in the
way a drug is distributed throughout the body (Barchas, Berger, Ciaranello and
Elliot, 1977).
These are: 1) cell Walls, 2) Walls of capillary vessels of the circulatory system,
3) the blood-brain barrier (BBB), and 4) the placental barrier.
Cell Membranes: In order to be absorbed from the intestine or gain access to the interior of a
cell, a drug must be able to penetrate the cell membranes (Spence and Mason,
1979). The characteristic feature of cell membranes are fat molecules coated by
a protein layer on each surface. Like a bimolecular Sandwich the fat molecules
(cheese) are sandwiched between two layers of protein (the bread). Only drugs
that are soluble in fat are permeable and can pass through the cell membrane.
The cell membrane also contains small pores that allow water-soluble molecules
to pass through. Most drugs are too large to pass through the pores and, thus,
most water-soluble, fat-insoluble drugs cannot pass through the cellular
barrier.
Blood Capillaries: Within a minute or so of a drug entering the bloodstream, it is
distributed fairly evenly through the circulatory system (Cooper, Bloom and
Roth, 1991). However, most drugs are not confined to the bloodstream and are readily exchanged back and forth
across the blood capillaries. The capillary walls contain pores that are large
enough for most drugs to pass through, therefore it does not matter whether a
drug is fat-soluble or insoluble for it to pass through.
Blood-Brain Barrier (BBB): For drugs to enter the central nervous system (CNS) they must be able to
penetrate the BBB (Cooper, Bloom and Roth, 1991). The BBB increases the
permeability of the capillary membranes thus protecting the brain from various
substances that would otherwise be harmful (Spence and Mason, 1979). Capillaries
of the brain are tightly joined making them smaller and more difficult to
traverse. But, a second barrier protects the CNS. The outer cell walls are
covered by a foot-like sheaf structure that arises from a nearby cell called an
astrocyte. Thus, for a substance to enter the brain it must traverse not only
the capillary wall but also the membranes of the astrocytes in order to reach
their target cells.
Placental Barrier: Among all the membrane systems of the body, the placenta is unique: it separates
two distinct human beings with differing genetic compositions, physiological
responses, and sensitivities to drugs (Barchas, Berger, Ciaranello and Elliot,
1977). The fetus obtains essential nutrients and eliminates metabolic waste
products through the placenta without depending on its own organs, many of which
are not yet functioning. This dependence of the fetus on the mother places it at
the mercy of the placenta when foreign substances appear in the mother’s blood.
References
Barchas, J.D., Berger, P.A., Ciaranello, R.D. and Elliot, G.R. (1977). Psychopharmacology. From Theory to Practice. New York: Oxford University Press.
Cooper, J.R., Bloom, F.E. and Roth, R.H. (1991). The Biochemical Basis of Neuropharmacology (6th Edition). New York: Oxford University Press.
Goldstein, A. (1994). Addiction. From Biology to Drug Policy. New York: W.H. Freeman & Company.
Gilman, A.G., Rail, T.W., Niles, A.S. and Taylor, P. (eds) (1990). Goodman and Gilman’s The Pharmacological Basis of Therapeutics (8th Edition). New York: Pergamon Press.
Spence, A.P. and Mason, E.B. (1979). Human Anatomy and Physiology. Menlo Park, California: The Benjamin/Cummings Publishing Company.
Zweben, J.E. and Sorensen, J.L. (Jul-Sep 1988). Misunderstandings about methadone. Journal of Psychoactive Drugs 20(3): 275-281.
Bibliography List
Understanding pharmacology can be difficult for the person without a scientific background.
This does not mean that one should ignore this area of methadone because
it is important for patients to have some basic knowledge in order to know about
their dose. Below are some classic texts with information about pharmacology.
Some are more difficult than others and you should first look through a
text prior to purchasing it to insure that you have the correct information.
Brecher, E.M., 1972. Licit and Illicit Drugs. The Consumers Union Report on Narcotics, Stimulants, Depressants, Inhalants, Hallucinogens, and Marijuana. Boston: Little, Brown and Company.
Cooper, J.R.; Bloom, F.E.; Roth, R.H., 1991. The Biochemical Basis of Neuropharmacology (6th Edition). New York: Oxford University Press.
Eccles, J.C., 1977. The Understanding of the Brain. New York: McGraw-Hill.
Gilman, A.G., Rail, T.W., Niles, A.S. and Taylor, P. (eds), 1990. Goodman and Gilman’s The Pharmacological Basis of Therapeutics (8th Edition). New York: Pergamon Press.
Goldstein, A. 1994. Addiction. From Biology to Drug Policy. New York: W.H. Freeman & Company.
Lowinson, J.H., Ruiz, P., Millman, R.B. and Langrod, J.G. (eds) 1992. Substance Abuse: A Comprehensive Textbook. Baltimore: Williams and Wilkens.
Pratt, W.B.; Taylor, P. (eds), 1990. The Principles of Drug Action. The Basis of Pharmacology (3rd Edition). New York: Churchill Livingstone.
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