Maintenance Treatment
The medical-distributive model, is based on the philosophy that if the medical profession finds a person who has a disorder that cannot be treated, the medical profession is bound to make the person as comfortable as possible. The disorder in this case is drug dependence. There are many who believe that drug-dependent individuals are simply not curable. Therefore everything possible should be done to make that person�s life complete and more cor�fortable. One way that this may be accomplished is by maintaining a person on their drug of choice. (Duncan and Gold, 1982)
Maintenance programs have considerable historical precedent. Treating alcoholics by giving them alcohol in fixed, limited doses at regular intervals in order to prevent withdrawal illness is far older than the term alcoholism itself. The Spanish colonial government of the Phillipines operated a maintenance program that dispensed opium to Chinese opium addicts there. Prior to the 1920�s, numerous clinics in the United States maintained opiate addicts on oral or injectable morphine but these programs were shut down by the American government at the beginning of their long �war on drugs.� Medical prescription of heroin to addicts continued in England until the 1970�s when pressure from the United States resulted in their closure in favor of methadone maintenance programs.
Contemporary maintenance treatment typically involves the substitution of a more socially acceptable drug for a less socially acceptable one that has much the same effects. Such approaches have often been criticised for failure to cure the addiction � only making the addict more comfortable while leaving him an addict, as described above. In terms of accepted medical definition, however, addiction to a drug is only a disorder if it is producing negative medical or social consequences. The maintenance patient, therefore, can be said to have been cured of his disorder even though he continues to be physically addicted.
Methadone Maintenance
Methadone is a synthetic drug with opiate-like effects that was developed during World War Two by German scientists at I.G. Farbendustrie at Hoechst-am-Main as a substitute for morphine, which was in short supply. It never came into any widespread use as a pain medication but by 1950 it was in use by the American Public Health Service to prevent withdrawal in heroin addicts.
In response to growing concern over heroin addiction, the New York City Health Research Council awarded a grant to Dr. Vincent Dole, a medical researcher at Rockefeller University, to study the possibility of medical treatment for the addiction. Dr. Dole was inspired by the book, The Heroin Addict as Patient, and employed its author, psychiatrist Marie Nyswander, as his assistant. Their initial attempts to maintain heroin addicts on morphine were not successful because of the continual need to increase the patient�s dosage and because the two or three daily doses were time consuming and each was followed by a period of somnolence that wasted even more time. It was apparently only in the process of terminating their study that Dole and Nyswander switched the patients to methadone with the intent of gradually reducing their dose.
Methadone, however, proved to be what they had been looking for. Because of its longer action, methadone need be administered only once per day. It did not need to be injected, although it could be. It produced less sleepiness than did heroin or morphine. Most importantly, the dosage did not need to be continually increased. Once a tolerance dose had been reached the patient�s tolerance did not increase further unless the dosage was intentionally increased.
While patients on methadone maintenance remained physically addicted, they no longer needed to resort to criminal activity to support an expensive habit. And they no longer had to spend most of each day acquiring the money to buy drugs and then obtaining the drugs. This permitted them to become productive citizens, holding steady employment or pursuing an education, as well as taking an active role in family life. Between 1964 and 1968 criminal activity among their patients was reduced by more than 90 percent and the majority were participating members of family units (Dole, Nyswander, and Warner, 1968).
In clinics throughout the world, methadone maintenance treatment patients have been restored to productive lives. Many have furthered their education, obtained training and employment, resumed or established careers and businesses, improved their physical and mental well-being, and renewed family relationships.
Buprenorphine Maintenance
Methadone is not the only alternative to heroin and morphine for substitute maintenance of heroin addicts. Another alternative of increasing popularity is buprenorphine. In France, where methadone has only limited availability from specialist clinics, buprenorphine maintenance has been extensively used since 1996, with over 55,000 patients under treatment.
Buprenorphine is a partial mu agonist. This means that it binds to and stimulates the same mu opiate receptors in the brain as does morphine or heroin. It, therefore, produces much the same effects as morphine or heroin, including pain relief, euphoria, sedation, and respiratory depression. But because it is only a partial agonist buprenorphine activates these receptors to a lesser degree than full mu receptor agonists such as morphine and heroin.
At the same time, because it is occupying the mu receptors there is no place for morphine or heroin to bind to them. Buprenorphine is released slowly from the mu receptor, producing a long-lasting effect. Therefore, it may be possible to give buprenorphine to patients every other day, rather than in the daily doses that methadone patients must receive.
A pilot sublingual buprenorphine program was launched in Imphal by Social Awareness Service Organization in 1999. Since methadone is not available at present or for the forseeable future in India, buprenorphine maintenance seems to be the future of maintenance treatment. Expansion of such programs can offer better lives for many addicts, greater safety for the communities in which they live, and diminished HIV transmission that threatens injecting drug users, their sex partners and their partners� sexual contacts.
Related Links
Effectiveness of Treatment for Opiate Dependent Drug Users Effective Treatment
High Dose Buprenorphine - What is its Role in Substitute Prescribing for Opiate Users? Buprenorphine
