6. Methadone Maintenance as a Treatment for Opioid Dependence

"Methadone is a long-acting µ-opioid receptor agonist, introduced in the 1960s, after being developed in Germany at the end of World War II.60 It has an onset of action within 30 minutes61-63 and an average duration of action of 24 to 36 hours. Its oral bioavailability is excellent and approaches 90%. These unique pharmacologic properties ideally lend themselves to once-daily dosing for maintenance therapy, although, when used to treat chronic pain, methadone is generally dosed 3 times daily. When the dosage is judiciously titrated, methadone treated patients generally do not experience euphoria or sedation, nor do they suffer impairment in the ability to perform mental tasks. One of the most important advantages of methadone is that it relieves narcotic craving, which is the primary reason for relapse. Similarly, methadone blocks many of the narcotic effects of heroin,64 which helps reinforce abstinence. Once a therapeutic dose is achieved, patients frequently can be maintained for many years with the same dose.65
"Methadone hydrochloride is available in 5- and 10-mg tablets as well as a 40-mg dispersible wafer. However, it is most frequently used for maintenance in a 10-mg/mL liquid concentrate. An intravenous solution is also available but has been linked with bradycardia when administered for sedation."

Mori J. Krantz, MD; Philip S. Mehler, MD, "Treating Opioid Dependence: Growing Implications for Primary Care," Archives of Internal Medicine, (Chicago, IL: American Medical Association, February 2004), Vol. 164, p. 279.

7. Undertreated Chronic Pain and Development of Substance Dependence

"In our study, there was greater evidence for an association between substance use and chronic pain among inpatients than among MMTP [Methadone Maintenance Treatment Program] patients. Among inpatients, there were significant bivariate relationships between chronic pain and pain as a reason for first using drugs, multiple drug use, and drug craving. In the multivariate analysis, only drug craving remained significantly associated with chronic pain. Not surprisingly, inpatients with pain were significantly more likely than those without pain to attribute the use of alcohol and other illicit drugs, such as cocaine and marijuana, to a need for pain control. These results suggest that chronic pain contributes to illicit drug use behavior among persons who were recently using alcohol and/or cocaine. Inpatients with chronic pain visited physicians and received legitimate pain medications no more frequently than those without pain, raising the possibility that undertreatment or inability to access appropriate medical care may be a factor in the decision to use illicit drugs for pain."

Rosenblum, Andrew, PhD, Herman Joseph, PhD, Chunki Fong, MS, Steven Kipnis, MD, Charles Cleland, PhD, Russell K. Portenoy, MD, "Prevalence and Characteristics of Chronic Pain Among Chemically Dependent Patients in Methadone Maintenance and Residential Treatment Facilities," Journal of the American Medical Association (Chicago, IL: American Medical Association, May 14, 2003), Vol. 289, No. 18, pp. 2376-2377.

8. Global Opiate Seizures

"Despite a 19 per cent decline in the quantity of opiates seized globally from 2017 to 2018 (calculated on the basis of converting those seizures into heroin equivalents), dropping to 210 tons, that was still the third highest amount ever reported and continued to exceed the quantity of pharmaceutical opioids seized.2 The overall decline in the quantity of opiates seized in 2018 was mostly due to a decrease by half in the quantity of morphine seized. The quantity of opium and heroin seized, by contrast, remained rather stable in 2018 (+2 per cent for opium; and -6 per cent for heroin on a year earlier).

"The opiate seized in the largest quantity in 2018 continued to be opium (704 tons), followed by heroin (97 tons) and morphine (43 tons). Expressed in heroin equivalents, however, heroin continued to be seized in larger quantities than opium or morphine. Globally, 47 countries reported opium seizures, 30 countries reported morphine seizures and 103 countries reported heroin seizures in 2018, suggesting that trafficking in heroin continues to be more widespread in geographical terms than trafficking in opium or morphine.

"The quantities of opium and morphine seized continued to be concentrated in just a few countries in 2018, with three countries accounting for 98 per cent of the global quantity of opium seized and 97 per cent of the global quantity of morphine seized. By contrast, seizures of heroin continue to be more widespread, with 54 per cent of the global quantity of heroin seized in 2018 accounted for by the three countries with greatest seizures."

World Drug Report 2020. Booklet Three: Drug Supply. June 2020. United Nations publication, Sales No. E.20.XI.6).

9. Health Risks from Heroin Use

"Chronic users may develop collapsed veins, infection of the heart lining and valves, abscesses, and liver or kidney disease. Pulmonary complications, including various types of pneumonia, may result from the poor health of the abuser as well as from heroin’s depressing effects on respiration. In addition to the effects of the drug itself, street heroin often contains toxic contaminants or additives that can clog blood vessels leading to the lungs, liver, kidneys, or brain, causing permanent damage to vital organs."

National Institute on Drug Abuse, DrugFacts: Heroin (Rockville, MD: US Department of Health and Human Services, Last Revised March 2010), last accessed Jan. 12, 2013.

10. Law Enforcement and Treatment Indicators of Heroin Use in the US, 2013

"Other Highlights – Younger Heroin Users:
"• Eight CEWG area representatives noted either increases in primary heroin treatment admissions for young adults (age 18–25) or high proportions of admissions for this age group compared with other age groups. A younger heroin user population was reported in treatment data in Denver and Colorado, Detroit and Michigan, Los Angeles, Minneapolis/St. Paul, St. Louis, San Diego (based on 2012 treatment data), Seattle, and Texas. The area representative from Chicago reported an increase in heroin use by young suburbanites as a key finding for 2013.
"Other Highlights – Cross-Area Data Sources
"Treatment Admissions:
"• Primary heroin treatment admissions ranked first in proportions of total treatment admissions in 2013 in 6 of 17 CEWG reporting areas—Baltimore City, Boston, Detroit, Maryland, St. Louis, and San Francisco—and they ranked second in 2 areas: Cincinnati and Seattle (table 1). Boston (56.6 percent) and Baltimore City (49.5 percent) had the highest proportions of primary heroin treatment admissions in 2013; Atlanta had the lowest, at 6.1 percent (table 8; figure 5).
"• Injection was the most frequently reported mode of heroin administration in 12 of 16 reporting CEWG areas in 2013. Proportions of heroin admissions injecting the drug ranged from 15.0 percent in Atlanta to 87.1 percent in South Florida/Broward County (table 9). Inhalation or intranasal use was the most frequent mode of heroin administration reported by heroin admissions in 2 of 17 areas: Baltimore City, at 57.0 percent, and Detroit, at 59.8 percent. However, this mode was relatively rarely reported among treatment admissions in Phoenix and Denver (at 3.8 and 4.3 percent, respectively). Smoking was reported by less than 2.0 percent of the heroin admissions in 9 of 16 CEWG areas reporting. Phoenix had the highest proportion of heroin treatment admissions whose primary mode of administration was smoking, at 28.1 percent (table 9)."

"Epidemiologic Trends in Drug Abuse: Proceedings of the Community Epidemiology Work Group, Highlights and Executive Summary, June 2014" (Bethesda, MD: National Institute on Drug Abuse, September 2014), p. 21.