Question 20: Can methadone and buprenorphine be abused?
Answer: Both methadone and buprenorphine can be diverted from their intended recipients. This diversion occurs in countries that provide these medications via supervised dispensing (e.g., pharmacies) and by prescription. Oftentimes, this diversion is by individuals who are seeking a therapeutic benefit (e.g., unobserved treatment). Other times, this diversion results in abuse. The extent of these two types of diversion varies, although most studies note that the benefits of providing the treatment outweigh the risks associated with diversion. For instance, the efficacy of methadone has been demonstrated over the past 40 years (O’Connor and Fiellin, 2000). The provision of methadone and buprenorphine treatment was associated with a 75-percent decrease in fatal heroin overdoses in France (Lepere, Gourarier, Sanchez, et al., 2001; Auriacombe, Fatseas, Dubernet, et al., 2004).
In studies that have compared death rates from heroin overdose among those who are untreated and those who receive methadone, deaths are higher among untreated opioid-dependent individuals (Capelhorn, Dalton, Haldar, et al., 1996,; Zanis and Woody, 1998).
Research Highlights
Methadone Abuse
Methadone can be diverted for oral or intravenous use (Fiellin and Lintzeris, 2003; Green, James, Gilbert, et al., 2000). Some diverted methadone can result in fatal overdoses; however, the rate of overdose among patients enrolled in methadone maintenance is low. A meta-analysis revealed a relative risk of death of 0.25 (95% CI: 0.19-0.33) for patients receiving methadone maintenance (Capelhorn et al., 1996). A study of nearly 10,000 individuals inducted onto methadone determined that the mortality rate was 7.1 deaths per 10,000 inductions (95% CI: 1.8± 12.4). In this same study, 51 percent of methadone-related deaths occurred in people who were not registered in methadone maintenance (Zador and Sunjic, 2002).
In addition, while methadone may be detected in drug-related deaths, it is often not the causative agent. In one study in the west of Scotland, during the period 1991–2001, methadone alone was judged to be the causative agent in only 29 percent (56) of drug-related deaths (Seymour, Black, Jay, et al., 2003).
Similarly, with the increased use of methadone as a treatment for chronic pain, the majority of methadone-related deaths in Australia and the United States are believed to be associated with the use of this medication for pain treatment instead of treatment of opioid dependence (Center for Substance Abuse Treatment, 2004).
Buprenorphine Abuse
As a partial agonist, buprenorphine has less potential for abuse than most full agonists. However, there is a reinforcing effect that subjects can experience with buprenorphine administration, especially via the injection route. This reinforcement is less likely if the subject has recently used a full agonist compound; in fact, buprenorphine can lead to a painful and uncomfortable precipitated withdrawal under this scenario. In addition, the development of a tablet that combines buprenorphine with naloxone, in a 4 to 1 ratio, has demonstrated decreased abuse potential and the ability to precipitate withdrawal in patients who are receiving a full opioid agonist (Mendelson, Jones, Welm, et al., 1999).
When the buprenorphine/naloxone combination tablet is taken sublingually, as prescribed, naloxone is poorly absorbed, and the patient receives a buprenorphine effect. However, if the tablet is dissolved and injected, the naloxone will antagonize the buprenorphine, resulting in a range of reactions, including blockade of opioid effects and precipitation of an immediate withdrawal. In this way, the combination gives the therapeutic benefit but greatly reduces opportunities for abuse by injection.
References
Auriacombe M, Fatseas M, Dubernet J, Daulouede JP, Tignol J. French field experience with buprenorphine.American Journal on Addictions 2004;13(Suppl 1):S17-28.
Capelhorn JR, Dalton MS, Haldar F, Petrenas AM, Nisbet, JG. Methadone maintenance and addicts' risk of fatal heroin overdose. Substance Use and Misuse 1996;31:177-96.
Center for Substance Abuse Treatment. Methadone-Associated Mortality: Report of a National Assessment, May 8-9, 2003. CSAT Publication No. 28-03. Rockville, MD: Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, 2004.
Fiellin DA, Lintzeris N. Methadone syrup injection in Australia: a sentinel finding? Addiction 2003;98:385-386.
Green H, James RA, Gilbert JD, Harpas P, Byard RW. Methadone maintenance programs–a two-edged sword?American Journal of Forensic Medicine & Pathology 2000;21(4):359-61.
Lepere B, Gourarier L, Sanchez M, Adda C, Peyret E, Nordmann F, et al. Reduction in the number of lethal heroin overdoses in France since 1994. Focus on substitution treatments. Annales de Medecine Interne 2001;152:5-12.
Mendelson J, Jones RT, Welm S, Baggott M, Fernandez I, Melby AK, et al. Buprenorphine and naloxone combinations: the effects of three dose ratios in morphine-stabilized, opiate-dependent volunteers.Psychopharmacology 1999;141(1):37-46.
O'Connor PG, Fiellin DA. Pharmacologic treatment of heroin-dependent patients. Annals of Internal Medicine2000;133:40-54.
Seymour A, Black M, Jay J, Cooper G, Weir C, Oliver J. The role of methadone in drug related deaths in the west of Scotland. Addiction 2003;98(7):995-1002.
Williamson PA, Foreman KJ, White JM, Anderson G. Methadone-related overdose deaths in South Australia, 1984-1994. How safe is methadone prescribing? Medical Journal of Australia 1997;166(6):302-05.
Zador DA, Sunjic SD. Methadone-related deaths and mortality rate during induction into methadone maintenance, New South Wales, 1996. Drug & Alcohol Review 2002;21(2):131-36.
Zanis DA, Woody GE. One-year mortality rates following methadone treatment discharge. Drug & Alcohol Dependence 1998;52:257-60
In This Section
- Certificate Programs
- Methadone Research Web Guide
- Acknowledgments
- Introduction
- Part A
- Part B
- Question 1: Is methadone maintenance treatment effective for opioid addiction?
- Question 2: Does methadone maintenance treatment reduce illicit opioid use?
- Question 3: Does methadone maintenance treatment reduce HIV risk behaviors and the incidence of HIV infection among opioid-depen
- Question 4: Does methadone maintenance treatment reduce criminal activity?
- Question 5: Does methadone maintenance treatment improve the likelihood of obtaining and retaining employment?
- Question 6: What effect can methadone maintenance treatment have on the use of alcohol and other drugs?
- Question 7: What components of methadone maintenance treatment account for reductions in AIDS risk behaviors?
- Question 8: Do risk factors for HIV infection acquisition and transmission differ for women compared with men in methadone maint
- Question 9: Is methadone maintenance treatment effective for women?
- Question 10: Is methadone safe for pregnant women and their infants?
- Question 11: Is it necessary to reduce methadone dose or detoxify women from methadone during pregnancy to protect the f
- Question 12: Is the long-term use of methadone medically safe, and is it well tolerated by patients?
- Question 13: Are there program characteristics associated with the success of methadone maintenance treatment?
- Question 14: Are there patient characteristics associated with the success of methadone maintenance treatment?
- Question 15: Are there cost benefits to methadone maintenance treatment?
- Question 16: What are the retention rates for methadone maintenance treatment?
- Question 17: Is mandated methadone maintenance treatment as effective as voluntary treatment?
- Question 18: What is the role of L-alpha-acetyl-methadol (LAAM)?
- Question 19: How do buprenorphine and methadone compare?
- Question 20: Can methadone and buprenorphine be abused?
- Part C
- Part D
- Methadone Research Web Guide Tutorial
- Questions: Methadone Research Web Guide
- Answers: Methadone Research Web Guide
- Methadone Research Web Guide
- Degree Programs
- Virtual Lectures
- Research Publications
Important Dates
NIDA International Forum
June 14–17, 2013
Online Registration Deadline:
May 6, 2013
FELLOWSHIPS
IAS/NIDA Fellowships
Application Deadline:
February 10, 2013
NIDA International Program Fellowships
Application Deadline:
April 1, 2013
GRANTS
Global Health Program for Fellows and Scholars
Application Deadlines: Vary
MEETINGS
American Association for the Advancement of Science
February 14–18, 2013
Boston, Massachusetts, USA