Question 6: What effect can methadone maintenance treatment have on the use of alcohol and other drugs?

Answer: Research outcomes are mixed regarding the effect of methadone maintenance treatment on the use of illicit drugs other than opioids. That is, some research indicates that methadone maintenance treatment is associated with decreases in the use of alcohol, cocaine, and marijuana; other research indicates increases in the use of these drugs. It is important to note that the medication methadone has no direct effect and is not intended to have an effect on rates of alcohol and other drug use. Patients receiving methadone maintenance who disengage from interactions with others who are actively using drugs are less likely to engage in these behaviors. In addition, reductions in alcohol and drug use result from the counseling services included in methadone maintenance treatment. When these services are specifically designed to reduce alcohol and other drug use, such reductions are likely.

Research Highlights

• In the Drug Abuse Reporting Program (DARP) studies, there were reductions in nonopioid drug use (except marijuana) among 895 methadone maintenance patients, comparing the 2-month period before admission and the year following discharge. The reduction in nonopioid use was 13 percent–from 54 percent of patients who reported any use before admission to 41 percent at the 1-year followup point (Simpson and Sells, 1982).
• In the 12-year DARP followup study, “heavy drinking” was reported by 21 percent of the sample in the month before treatment; it rose to 31 percent during the first year afterward and then declined to 22 percent by year 12. One-half of the patients reported substituting alcohol for opioids after stopping daily illicit opioid use (Lehman, Barrett, and Simpson, 1990).
• In a study comparing buprenorphine maintenance with methadone maintenance for patients with opioid dependence and cocaine abuse, both treatments resulted in significant declines in opioid use but were indistinguishable in terms of their effect on comorbid cocaine use (Schottenfeld, Pakes, Oliveto, et al., 1997).

Methadone Maintenance Treatment and General Drug Abuse–Among three cohorts of new-admission patients in methadone maintenance treatment, Ball and Ross (1991) found that the use of all illicit drugs, except marijuana, decreased markedly in relation to time in treatment. These three cohorts had been in treatment 6 months, 4.5 years, or more than 4.5 years.

In the Treatment Outcome Perspective Study (TOPS), 90 percent of methadone maintenance treatment patients who reported drug use at intake reported a reduction in use during the first 3 months of treatment. For 80 percent, this reduction is large. In the year before treatment, less than 10 percent of methadone maintenance treatment patients were minimal drug users. During treatment, more than 50 percent of the patients were minimal drug users. During the 3 to 5 years after discharge, less than 32.5 percent were minimal drug users (Hubbard, Marsden, Rachal, et al., 1989).

In the National Treatment Outcome Research Study (NTORS), of 333 patients receiving methadone maintenance in the United Kingdom, overall declines were seen in the use of heroin, barbiturates, amphetamines, cocaine, and crack cocaine among patients receiving methadone maintenance. Alcohol use, however, did not change over time (Gossop, Marsden, Stewart, et al., 2000).

In another evaluation of 513 heroin users in methadone treatment in TOPS, a decline was observed in the use of cocaine, amphetamines, illegal methadone, tranquilizers, and marijuana, but not alcohol (Fairbank, Dunteman, and Condelli, 1993).

The Powers and Anglin study (1993) of 933 heroin addicts in methadone maintenance programs demonstrated that during episodes of methadone maintenance treatment, illicit opioid use decreased, but alcohol and marijuana levels increased moderately. Kreek (1991) observed that by 1990, alcoholism was identified in 40 or 50 percent of new admissions to methadone maintenance treatment programs, and cocaine abuse was found in 70 to 90 percent. She also estimated that 20 to 46 percent of patients in effective methadone maintenance treatment programs continue using cocaine, and 15 to 20 percent of methadone maintenance treatment patients regularly inject cocaine.

Methadone Maintenance Treatment and Cocaine Use–Among the TOPS patients who remained in methadone maintenance treatment at least 3 months, 26.4 percent had used cocaine regularly the year before treatment. This rate fell to 10 percent during the first 3 months of treatment but returned to 16 percent by 3 to 5 years after discharge. Altogether, 40 percent of methadone maintenance treatment patients who regularly used cocaine before treatment and stayed in treatment for at least 3 months abstained from cocaine use in the year after treatment (Hubbard et al., 1989).

In the TOPS studies, although 70 percent of heroin abusers had frequently used cocaine the year before treatment, it was the primary drug of choice for only 2 percent of methadone maintenance treatment patients (Hubbard et al., 1989).

In the new admissions group of a six-program study (n = 345), 46.8 percent of 126 patients had used cocaine in the past 30 days. Among the average-stay group (up to 4.5 years in treatment), 27.5 percent still used cocaine; this rate dropped to 17.2 percent among the long-term group of 146 patients who had been in continuous treatment for more than 4.5 years (Ball and Ross, 1991).

A study evaluating the effect of methadone dose on treatment outcomes noted that patients receiving 50 mg of methadone, compared with those receiving 20 mg or 0 mg, had a reduced rate of opioid-positive urine samples (56.4% vs. 67.6% and 73.6%, respectively; p < 0.05) and cocaine-positive urine samples (52.6% vs. 62.4% and 67.1%, respectively; p < 0.05) (Strain, Stitzer, Liebson, et al., 1993).

A systematic review examined the impact of methadone dose on cocaine use and found three studies that addressed the question. Results from the one study in which cocaine use was based on self-reported use showed no significant excess of use of cocaine among subjects treated with higher doses compared with subjects treated with lower doses. Pooled results from the two studies that used urine analysis and looked at an abstinence period longer than 3 weeks showed that higher methadone doses increased the probability that patients would stay abstinent from cocaine, compared with lower doses (RR = 1.81 [1.15, 2.85]) (Faggiano, Vigna-Taglianti, Versino, et al., 2003).

Methadone Maintenance and Marijuana Use–Among TOPS subjects, marijuana use was common: 55 percent of methadone maintenance patients who stayed in treatment for 3 months reported regular use in the year before admission. This decreased to 47 percent during the first 3 months of treatment, continued to decline immediately posttreatment, and decreased even more to 36.4 percent in the 3- to 5-year period after discharge. However, marijuana use appeared more resistant to change than other illicit substances (Hubbard et al., 1989). It should be considered that the treatment programs likely did not clinically address marijuana or other drug use.

Ball and Ross (1991) found that marijuana continued to be used quite regularly (an average of 13 to 16 days per month) by high percentages of all patient groups in methadone maintenance treatment: 48.4 percent of the new admissions, 47.7 percent of the average-stay group, and 37.2 percent of the patients in treatment more than 4.5 years.

In one study of 132 opioid addicts participating in methadone maintenance treatment programs, it was noted that during episodes of methadone maintenance treatment, levels of alcohol and marijuana use increased modestly (Powers and Anglin, 1993).

Methadone Maintenance and the Nonmedical Use of Prescription Drugs–In the TOPS studies, the regular nonmedical use of psychoactive prescription drugs by methadone maintenance treatment patients during the first posttreatment year decreased by one-third from the pretreatment period. Although 30.3 percent of this methadone maintenance group reported regular nonmedical use of prescription drugs (i.e., barbiturates, amphetamines, tranquilizers, sedatives, and hypnotics), nonmedical prescription drug use was a primary problem for only 1.9 percent of these patients at admission (Hubbard et al., 1989).

In the NTORS study, a decline was seen in the use of benzodiazepines among patients receiving methadone maintenance (Gossop et al., 2000). In the TOPS studies, nonmedical prescription drug use declined during methadone maintenance treatment, increased immediately following discharge, and declined again to 10 percent of patients 3 to 5 years following discharge (Hubbard et al., 1989).

Ball and Ross (1991) found that although the nonmedical use of sedatives other than barbiturates was acknowledged by 31.8 percent of new admissions to methadone maintenance treatment, the percentage of sedative-using patients who had been in treatment for more than 4.5 years was less than half that of the new admission group (14.5 percent).

Methadone Maintenance Treatment and Alcohol and Other Drug Use–In the TOPS studies, improvements in the use of illicit and nonprescription drugs follow a pattern of (1) a dramatic reduction during treatment, (2) a sharp increase immediately after discharge, and (3) a leveling off at an impressively reduced rate for up to 5 years of followup contacts (Hubbard et al., 1989).

 

Figure 21 illustrates that as reported by the TOPS study of 4,184 patients, methadone maintenance treatment was associated with reductions in (1) any illicit opioid use, (2) any cocaine use, (3) any marijuana use, and (4) alcohol abuse (the 1-percent reduction noted here is not statistically significant) (Hubbard et al., 1989).

“Any opioid use” declined from 63 percent pretreatment to 17 percent 1 year posttreatment. This was the most dramatic decline. “Any cocaine use” declined from 26 percent to 18 percent. “Any marijuana use” declined from 55 percent pretreatment to 46 percent 1 year posttreatment. Alcohol abuse remained almost steady, declining slightly from 25 percent to 24 percent.

References

Ball JC, Ross A. The Effectiveness of Methadone Maintenance Treatment: Patients, Programs, Services, and Outcomes. New York: Springer-Verlag, 1991.

Faggiano F, Vigna-Taglianti F, Versino E, Lemma P. Methadone maintenance at different dosages for opioid dependence. The Cochrane Database of Systematic Reviews, Issue 3, 2003.

Fairbank JA, Dunteman GH, Condelli WS. Do methadone patients substitute other drugs for heroin? Predicting substance use at 1-year follow-up. American Journal of Drug & Alcohol Abuse 1993;19(4):465-74.

Gossop M, Marsden J, Stewart D, Rolfe A. Patterns of improvement after methadone treatment: 1 year follow-up results from the National Treatment Outcome Research Study. Drug & Alcohol Dependence 2000;60(3):275-86.

Hubbard RL, Marsden ME, Rachal JV, Harwood HJ, Cavanaugh ER, Ginzburg HM. Drug Abuse Treatment: A National Study of Effectiveness. Chapel Hill: University of North Carolina Press, 1989.

Kreek MJ. Using methadone effectively: achieving goals by application of laboratory, clinical, and evaluation research and by developing of innovative programs. In: Pickens RW, Leukefeld CG, Schuster CR (eds.). Improving Drug Abuse Treatment. NIDA Research Monograph Series 196. Rockville, MD: National Institute on Drug Abuse, 1991.

Lehman WEK, Barrett ME, Simpson DD. Alcohol use by heroin addicts 12 years after drug abuse treatment. Journal of Studies in Alcohol 1990;51(3):233-44.

Powers KI, Anglin MD. Cumulative versus stabilizing effects of methadone maintenance. Evaluation Review1993;17(3):243-70.

Schottenfeld RS, Pakes JR, Oliveto A, Ziedonis D, Kosten TR. Buprenorphine vs methadone maintenance treatment for concurrent opioid dependence and cocaine abuse. Archives of General Psychiatry 1997;54(8):713-20.

Simpson DD, Sells SB. Effectiveness of treatment for drug abuse: an overview of the DARP research program.Advances in Alcohol and Substance Abuse 1982;2(1):7-29.

Strain EC, Stitzer ML, Liebson IA, Bigelow GE. Dose-response effects of methadone in the treatment of opioid dependence. Annals of Internal Medicine 1993;119:23-37