A D D I C T I O N T R E AT M E N T

Methadone MaintenanceTreatment (MMT)Stewart B. Leavitt, PhD, Editor, Addiction Treatment Forum

Addiction to heroin and other opioids posesserious problems for communities, families, andindividuals. Solutions sometimes seem uncertain,difficult, and controversial.

During more than 40 years since its develop-ment, methadone maintenance treatment (MMT)has helped millions of persons in recovery fromopioid addiction; allowing them to improve theirhealth, redeem their family and social lives, holddown steady jobs or return to school, and generally

become productive tax-paying citizens in theircommunities. Yet, the merits and effectiveness ofaddiction treatment in general and MMT inparticular have not been universally understoodand accepted.

This booklet focuses on the evidence-based con-clusions and educated commentary of crediblesources to provide a current and balanced per-spective on the treatment of opioid addiction withmethadone.

Addiction tragically“tricks” the brain intothinking opioid drugs

are needed forsurvival.

A Community-Centered Solutionfor Opioid Addiction

Understanding Addiction As A Brain Disease

At one time, drug addiction was viewed as a failure of willpower or a flawof moral character. It was not recognized as a disease of the brain, in the sameway that mental illnesses previously were not viewed as such. Medical authori-ties have now accepted drug addiction as a chronic, relapsing disorder thatalters normal brain function, just as any other neurological or psychiatric illness.Its development and expression are influenced by genetic, biological, psychoso-cial, and environmental factors. Outwardly, drug addiction is often characterizedby impaired control over continued drug use, compulsive use despite harmfulconsequences, and/or intolerable drug craving.1,2

Addiction to opioid drugs is particularly insidious because the brain producesits own opioid substances (e.g., endorphins) that are vital for survival. In effect,the brain is “tricked” by external, short-acting opioid agents into responding asif they are biologically essential. Once addiction sets in, brain chemistry becomesunbalanced, and the person becomes physically, emotionally, and mentallydysfunctional unless more opioid drug is regularly taken. Chronic opioid abusecauses physiologic derangements lasting months or years after the last drug-taking episode. So, even if opioid-abstinence is eventually achieved, relapsesare common without ongoing therapy of some sort.1,2

Facts & Consequences of Opioid Addiction in America

2

Medication-freetherapies alonecannot stabilizethe chemicalupsets of opioidaddiction.

High-purity, low-price,heroin appeals toyouth, resulting inaddiction, the spreadof serious diseases,and fatal drugoverdoses.

Many public officials and healthcare providers have expressed a strong biasfavoring “drug-free” treatment and eschewing the use of any medicationsduring recovery.3 However, such therapies for opioid addiction alone cannotstabilize the chemical upsets associated with addiction and return brainfunction to a more normal state.

The common stereotype depicts opioid-addicted persons as social misfitsand outcasts; however, such addiction is common throughout all segments ofsociety and in every community.4 Widely available and affordable access toeffective, community-based clinics providing methadone maintenance for thedisorder provides a viable solution for helping to stem America’s opioid-drugaddiction crisis.

Heroin Continues To Take A TollIn the most recent reports, nearly 4 million Americans were classified as

dependent on or abusing illicit substances, and heroin addiction has continuedas a major concern.5 Heroin is derived from opium — as are morphine andcodeine — a product of the poppy plant and classified as an opiate narcotic.A broader term, “opioid,” encompasses opium by-products and the manysynthetic drugs (such as, oxycodone, hydrocodone, propoxyphene, and othersincluding methadone) with properties similar to opium.6,7

The White House’s Office of National Drug Control Policy (ONDCP) hasestimated that there are more than 800,000 untreated chronic heroin users inthe United States, although this number is probably undercounted.3 Data on ad-missions to substance abuse treatment programs indicate that heroin dependencehas surpassed cocaine in some cases to become the most common diagnosisbehind alcoholism. Of interest, admissions for heroin use via inhalation havebeen increasing due to its higher purity.5,8

Reports from drug enforcement agencies indicate that during the past 2decades heroin has become 30 times less expensive while its purity has increas-ed more than 10-fold. A heroin “fix” can be purchased for as little as $5 and itspurity exceeds 70% in some major cities.9-11 Availability of low-cost, high-purityheroin has fostered increased use, since it can be smoked, snorted, or otherwiseinhaled without the need for injection needles. This has attracted many newusers among youth, white, and middle class populations.5,9,11,12 Their experimen-tation eventually leads to injection and more severe addiction, and miscal-culations of drug purity have led to fatal overdoses.3,13

The impact on public health has been severe. A typical intravenous-heroinabuser may inject 4 or more times each day and this has been associated withmany serious communicable diseases, including: HIV/AIDS, hepatitis B and C,and tuberculosis. More than a third of all adult and adolescent AIDS casesreported in the U.S. have been associated with injection drug use.12,14 The preva-lence of hepatitis C among intravenous-drug users ranges up to 90%,7,15 andtwo-thirds may be infected with hepatitis B.14 Drug abusers are from 2 to 6 timesmore likely to contract tuberculosis than nonusers,14 and almost half of thepatients in some opioid addiction treatment programs have positive tuberculinskin tests.7 Finally, during the 1990s, heroin-related emergency departmentvisits more than doubled and the annual death toll increased by 74%.3,16

A D D I C T I O N T R E AT M E N T

3

Opioid Analgesics Are A Major ConcernOne of the most troubling and increasing problems facing American commu-

nities is the abuse of opioid analgesic medications (painkillers), which has beenassociated with addiction, drug overdoses, and deaths. The prevalence ofprescription-opioid abuse has surpassed illicit drug abuse.13,17 For example, in2002 an estimated 4.4 million persons took pain relievers for non-medicalpurposes, compared with 3.9 million persons who abused an illicitsubstance, such as heroin, cocaine, etc.5

Because methadone has become more widely prescribed as a potentand cost-effective analgesic, it has been misused along with other opi-oids like oxycodone, hydrocodone, and morphine.17 Consequently,throughout the past decade, there have been sharp increases in hospitalemergency department visits associated with opioid analgesics (seegraph),18 and also an upsurge in widely publicized overdose deathsattributed to these drugs.13,17

As with any other opioid drug, methadone can be dangerous andlife-threatening if improperly used, and there have been long-standing con-cerns about the diversion of methadone for illicit purposes.16 However, in 1995,a distinguished committee assembled by the Institute of Medicine concludedthat, “the actual level of abuse and harm from illicit methadone falls short ofits hypothetical potential for abuse… and is small relative to heroin andcocaine.”19

Still, there were increasing reports of methadone-associated deaths in somecommunities during 2001 to 2003. MMT clinics were blamed as the source ofdiverted drugs and methadone was stigmatized as a “killer drug that should becurtailed.” In response, an expert panel convened by the government’sSubstance Abuse and Mental Health Services Administration (SAMHSA)unanimously concluded that opioid analgesics in general, most oftencombined with other drugs or alcohol, were the major source of theproblems. Methadone itself was documented as the sole and directcause of death in relatively few cases, and the greatest source of thedrug came from its prescription by physicians as a painkiller; not fromMMT clinics.13

In fact, MMT programs provide a valuable service to their communi-ties by treating residents who, for one reason or another, becomeaddicted to opioid painkillers. In one study, more than 80% of patientsadmitted to MMT programs had been using prescription opioid medica-tions at higher than therapeutic dosages, with or without heroin (seepie graph).20 Nearly half had started their addiction by first misusinganalgesics and 24% were being treated solely for opioid-analgesicdependency.

The majority of patients initiated opioid use due to ongoing pain problems,rather than recreational use.20 However, experts have cautioned that fears ofproducing dependency on opioid medications should not deter their appropri-ate prescription for patients in pain who would benefit from them. Pain isseriously undertreated in the U.S. and reducing the availability of opioidanalgesics would exacerbate that problem.17

Oxycodone

UnspecifiedOpioid

Methadone

Morphine

Hydrocodone

352%

288%

230%

210%

131%

Increases in emergencydepartment visits.

4

Beneficial Effects Of Methadone For Opioid Addiction

Methadone was developed by German scientists in the late 1930s. It wasapproved by the U.S. Food and Drug Administration (FDA) in 1947 as apainkiller, and by 1950 oral methadone also was used to treat the painfulsymptoms of persons withdrawing from opioids, usually heroin.19,21,22

In 1964, researchers at Rockefeller University, New York – headed by VincentDole and Marie Nyswander – believed that opioid addiction was a “metabolicdisease” that altered brain function and made it difficult for patients to remaindrug-free.10,23 Dole’s team discovered that an ongoing, daily dose of long-actingoral methadone –– maintenance treatment –– offered a number of beneficialeffects allowing otherwise debilitated opioid addicts to function more normally(see box).15,16,23-27

MMT was viewed as corrective therapy, rather than as a “cure” for opioidaddiction, and it had no or only limited efficacy in treating dependence onother substances of abuse.22 Dole wrote, “the most that can be said is thatthere seems to be a specific neurobiological basis for the compulsive use ofheroin by addicts and that methadone taken in optimal doses can correct thedisorder.”23

Oral methadone has demonstrated a favorable safety profile when properlyprescribed and used. No serious adverse reactions or organ damage have beenspecifically associated with continued methadone use extending more than 20years in some patients. Minor side effects, such as constipation or excess sweat-ing, may appear during early days of treatment and are easily managed.Women stabilized on methadone generally have more healthful pregnanciesand their newborns do not suffer any lasting adverse consequences.15,26 Further-more, methadone at appropriate dose levels does not hinder a patient’s intel-lectual capacities or abilities to perform work tasks.28

Adequate methadone dosing is critical for therapeutic success. Dole’soriginal research discovered that 80 to 120 milligrams of methadone per day,on average, was an effective dose. Dozens of studies since then have demon-strated that dosing in that range results in superior treatment outcomes, suchas better retention of patients in treatment and less illicit drug use.9,26,27 For avariety of reasons — such as, high tolerance to opioids, physical condition,mental status, concurrent medications, or prior use of high-purity heroin —many patients require much higher daily methadone doses for treatmentsuccess; sometimes exceeding 200 mg/day or more.15,26,29 Patients maintained oninadequately low doses are much more likely to use illicit opioids and respondpoorly to therapy.28

In 1997, an independent panel of experts convened by the NationalInstitutes of Health (NIH) to reach a consensus on effective treatments foropioid addiction concluded that, “Of the various treatments available [foropioid addiction], MMT, combined with attention to medical, psychiatric, andsocioeconomic issues, as well as drug counseling, has the highest probability ofbeing effective.”16

An adequate maintenancedose of methadone doesnot make the patient feel“high” or drowsy, so thepatient can generally carryon a normal life. Dailydrug-seeking to “feed ahabit” ceases.

Methadone can be takenonce daily by mouthwithout the use of injectionneedles, which limitsexposure to diseases likehepatitis and HIV.

Methadone’s gradual, long-lasting effects eliminatedrug hunger or craving.

There is little change intolerance to methadoneover time, so it does nottake more of the drug toachieve the same results.

Euphoria-blocking effectsof methadone make takingillicit opioids undesirable.

Used properly, methadoneis generally safe andnontoxic, with minimalside effects.

MMT Benefits

How Methadone Maintenance Treatment (MMT) Works

A D D I C T I O N T R E AT M E N T

5

Persons leaving

MMT and not

pursuing further

treatment are

almost certain

to relapse, with

potentially fatal

consequences.

COSTSAVINGS

$1

$7

Ongoing MMT Is Essential & Cost Effective,But Capacity Is Insufficient

Time in treatment is a critical factor for addiction recovery. Typically,methadone-maintained patients must attend a treatment program each day toreceive their oral dose of methadone; however, stable and compliant patients areusually allowed to take home a number of doses, thus reducing their clinic visits.3,30

Appropriate psychosocial therapy and other support services are integral compo-nents of ongoing MMT.

The NIH Consensus Panel16 and others31 concluded that patients treated forfewer than 3 months in MMT generally show little or no improvement. Studieshave routinely demonstrated reductions in illicit opioid use of up to 80% or moreafter several months, with the greatest reductions for patients who remain intreatment more than a year.3,19, 30-32 Patients often require MMT indefinitely, aswould be expected with any chronic medical condition. Once a patient has beenstabilized on MMT, withdrawal from methadone carries substantial risks.33

Virtually all who abandon MMT and do not pursue further treatmenteventually relapse34 and potentially overdose.13

Unfortunately, MMT is not available for all who might benefit, eventhough the number of patients in treatment has grown steadily andincrementally through the years (see graph).9,35,36 In 2004, there wereabout 1,100 MMT programs in 44 states; however, program capacity wassufficient to serve only a small fraction of opioid-addicted persons inthis country who needed it; especially considering the additional num-bers of persons addicted to opioid analgesics.3,15

Methadone treatment is a cost effective alternative to incarcerationor hospitalization.3,24,30 Studies have shown that it costs about $42,000 per yearto leave a drug abuser untreated in the community, $40,000 if the offender isincarcerated, and only about $3,500 for MMT.37 Furthermore, the National Instituteon Drug Abuse (NIDA) has reported that among MMT participants illegal activitydeclined by 52% and full time employment increased by 24%.3 Patients in MMTalso earn more than twice as much money annually as opioid addicts not in treat-ment, which can enhance their value as taxpaying citizens in the community.16

An often-quoted study of 150,000 patients — the California Drug and AlcoholTreatment Assessment (CALDATA) — found that for every $1 spent on addictiontreatment more than $7 in future costs were saved (see graph). MMT wasdetermined to be the lowest-cost, most effective treatment modality for opioidaddiction; whereas, programs offering only opioid detoxification showed nolong-term benefits at all.7

Deaths and illness associated with addiction are financially draining on society.Untreated opioid addicts have a death rate 3 to 4 times greater than patients inmethadone treatment.13,16 Furthermore, studies have consistently shown that therisk of communicable infections – HIV, hepatitis, tuberculosis – is significantlyreduced by MMT, even in the absence of complete illicit-drug abstinence.22,30,38 Ifmethadone clinics are closed communities pay a price. One study found that thecosts for crime, justice system (e.g., arrests), and welfare services in a communitythat closed its MMT program were 17% higher when compared with a localitywith an ongoing MMT clinic.7

# Patients(000s)

MMT Growth

1968 1973 1987 1991 1963 1999 2002 2004

7395

117

179205

220

0.4

82

Addiction treatment

provides a 700% return

on investment.

6

Past Practices And Misperceptions Have Hindered Progress

Through the years, MMT has fostered some negative attitudes and actionsby critics. A segment of public opinion has opposed the use of methadone fortreating opioid addiction and political initiatives have been enacted or proposedto thwart access to MMT.39,40 Many persons still perceive opioid dependence as aself-controllable “bad habit,” and dismiss MMT as an ineffective, addictive-narcotic substitution therapy.16,19

However, it has widely and authoritatively been recognized that methadoneis not merely a substitute for illicit opioids, and MMT does not simply replaceone addiction with another.3,10,13,15,37,39,41 Although methadone can cause physicaldependence, its steady and long-term action in the brain contrasts sharply withthe disruptive cycle of “highs” and “lows” produced by short-acting opioidsthat lead to addictive behaviors.9,15,24,42 Methadone substitutes a stable existencefor one of compulsive drug seeking and taking, criminal behavior, chronicunemployment, and high-risk sexual and drug-use behaviors.3

Unfortunately, during the early days of MMT there were problems as aresult of rapid clinic expansion in the face of decreased funding.24,43 A govern-ment report found that clinic policies, goals, and practices varied widely,3,41

and departures from recommended methadone doses, adopting a“less is more” approach, had pervaded many programs.9 Surveys since1988 have observed that a majority of U.S. MMT clinics once providedaverage methadone doses far below the 80 mg/day recommendedminimum.43 There have been improvements more recently, with most pro-grams achieving average doses of 80 mg/day or more (see graph). How-ever, many patients still receive inadequate amounts of methadone,43,44 andthey often respond poorly to treatment, just as would any individualsprescribed insufficient drug therapy for a chronic medical disorder.26,43

Regulations And Accreditation Promote “Best Practices”

MMT has been a tightly controlled medical specialty in the U.S. andmethadone itself is a highly regulated drug.9,16 Fairly recently, in 2001, oversightof MMT programs was transferred to SAMHSA’s Center for Substance AbuseTreatment (CSAT). Revised federal regulations emphasize improved patient careand increased healthcare practitioner discretion in meeting patients’ needs;particularly, allowing more liberal methadone dosing and permitting qualifiedpatients to take home doses for self-administration.30 However, state and localregulations may be more stringent, and they are in some cases.

As a component of the regulations, MMT programs must successfullycomplete an accreditation process similar to that required of much largerhealthcare organizations. Best-practice guidelines and standards have beendeveloped, reflecting the latest evidence promoting excellence in thetreatment of opioid addiction. Results to date indicate that MMT programaccreditation has been successful in improving patient care, safety, andtreatment outcomes.37

Average Dose (mg/day)

1988 1990 1993 1995 1998 2003

90

85

80

75

70

65

60

55

50

45

40

Methadone providesa stable existencethat replaces high-risk,self-destructive addictivebehaviors.

Revisedregulationsallow formore flexiblemethadonedosing andtake homeprivileges.

MMT Criticisms, Concerns, And Regulation

A D D I C T I O N T R E AT M E N T

7

Quality care for opioid-dependent persons also involves promoting theirreintegration, acceptance, and ongoing recovery from addiction in theircommunities. Toward those ends, MMT staff seek to develop an understandingof community values, needs, and resources; and, they strive to work collabora-tively with community leaders and organizations at all levels.

Addiction treatment is sometimes viewed as a form of social welfare. How-ever, from an MMT perspective, such treatment is a medical service that extendsbeyond benefitting opioid-addicted patients. Public safety, health, and eventu-ally the local economy often are the greater beneficiaries of methadonemaintenance treatment.3,37

Expanding Treatment

There is a provision in the revised federal regulations for office-basedphysicians, who have formal arrangements with established MMT programs, toprovide methadone maintenance.30,45 This has been widely endorsed by govern-ment3,16,19,32 and medical33,46 organizations. It is estimated that at least 7% of patientsin MMT clinic programs are sufficiently stable to be served in this manner –called methadone “medical maintenance” – and it would make additional MMTclinic capacity available for opioid addicts awaiting treatment. However, thisapproach has not been widely accepted and implemented.

In 2002, another opioid drug, buprenorphine, was approved by the govern-ment for prescription by qualified community-based physicians to treat opioidaddiction.26,47 However, it has been recognized that “buprenorphine is unlikelyto be as effective as more optimal-dose methadone, and therefore may not bethe treatment of choice for patients with higher levels of physical dependence[on opioids].”37,47 Also, without the close monitoring, psychosocial therapy, andother support provided by MMT clinics, the long-term benefits of buprenorphinefor some patients could be questionable.

Overcoming Stigma, Prejudice, And Misunderstandings

The World Health Organization and others have recognized that the stigma,prejudice, and misunderstandings surrounding persons with addictive disordersis a major barrier to their treatment and proper care.1,4 In particular, these neg-ative pressures have served as obstacles to persons entering methadone treat-ment, to doctors in treating opioid addiction, and to legislators and publichealth officials who could otherwise do more to make MMT widely available.Past policies have placed too much emphasis on protecting society frommethadone and not enough on protecting communities from the epidemics ofaddiction, violence, and infectious diseases that MMT can help reduce.19

Rather than embracing MMT as a solution, some short-sighted communitieshave rallied against the opening of new MMT clinics – even in the midst ofever-increasing opioid addiction problems – and forcing their citizens to travelhours each day to other locales for methadone treatment. Hopefully, better,evidence-based information and education will succeed in overcoming all ofthe barriers facing MMT for the benefit of patients, their families, and theircommunities.

Stigma, prejudice,and misunderstandingssurrounding methadone

have served asobstacles to persons

who would otherwiseenter treatment, todoctors who mightdo more in treating

opioid addiction,and to legislatorsand public health

officials who coulddo more to make

MMT available.

Meeting Challenges for Change In Communities

8

References1. Neuroscience of Psychoactive Substance Use and Dependence. Geneva:

World Health Organization; 2004.

2. Nestler EJ, Malenka RC. The addicted brain. Scientific American. March2004.

3. Office of National Drug Control Policy (ONDCP). Policy Paper: OpioidAgonist Treatment. Washington, DC: Office of National Drug ControlPolicy; March 1999.

4. Lewis D. Treatment works – the truth please. Brown Univ Digest AddictTheory Application. 1998;17(4).

5. 2002 National Survey on Drug Use and Health (NSDUH). Washington, DC:Substance Abuse and Mental Health Services Administration; 2003.

6. Heroin; Get The Facts. Albany, NY: New York State Office of Alcoholismand Substance Abuse Services (OASAS); 1997.

7. Kauffman JF, Woody GE. Matching Treatment to Patient Needs in OpioidSubstitution Therapy. Treatment Improvement Protocol (TIP) Series 20.Rockville, MD: U.S. Department of Health and Human Services; Center forSubstance Abuse Treatment;1995. DHHS Pub# (SMA) 95-3049.

8. New data show opiates take lead over cocaine in treatment admissions[press release]. Washington, DC: U.S. Department of Health and HumanServices; August 26, 1999.

9. Nadelman E, McNeely J. Doing methadone right. The Public Interest.1996;123:83-93.

10. Zweben JE, Payte JT. Methadone maintenance in the treatment of opioiddependence; a current perspective. West J Med. 1990;152:588-599.

11. National Drug Threat Assessment 2004. Washington, DC: National DrugIntelligence Center, U.S. Department of Justice; April 2004.

12. Heroin Abuse and Addiction. National Institutes on Drug Abuse (NIDA)Research Report Series; October 1997. NIH Pub# 97-4165.

13. Methadone Associated Mortality: Report of a National Assessment.Rockville, MD: Center for Substance Abuse Treatment; 2004. PublicationNo. 28-03.

14. Infectious diseases and drug abuse. NIDA Notes. August 1999;14(2):15. NIHpub #99-3478.

15. Payte JT, Zweben JE, Martin J. Opioid maintenance treatment. In: GrahamAW, et al., eds. Principles of Addiction Medicine. 3rd ed. Chevy Chase, MD:American Society of Addiction Medicine; 2003:751-766.

16. Effective Medical Treatment of Opiate Addiction. NIH ConsensusStatement. 1997(Nov 17-19);15(6):1-38. Bethesda, MD: National Institutesof Health.

17. Zacny J, Bigelow G, Compton P. et al. College on problems of drugdependence taskforce on prescription opioid non-medical use and abuse:position statement. Drug Alcohol Depend. 2003;69:215-232.

18. Percentage increase in hospital emergency department visits associatedwith opioid analgesics, 1994-2001. Washington, DC: Substance Abuse andMental Health Services Administration); 2002. DAWN Series D-23, DHHSPublication No. (SMA) 03-3781.

19. Rettig RA, Yarmolonsky A (eds). Federal Regulation of MethadoneTreatment. Committee on Federal Regulation of Methadone Treatment;Division of Biobehavioral Sciences and Mental Disorders; Institute ofMedicine (IOM). Washington, DC: National Academy Press; 1995.

20. Brands B, Blake J. Sproule B, Gourlay D, Busto U. Prescription opioid abusein patients presenting for methadone maintenance treatment. Drug AlcDep. 2004;73:199-207.

21. Payte JT. A brief history of methadone in the treatment of opioid depen-dence: a personal perspective. J Psychoactive Drugs. 1991;23(2):103-107.

22. Joseph H, Stancliff S, Langrod J. Methadone maintenance treatment(MMT): a review of historical and clinical issues. Mt Sinai J Med. 2000;67(5-6):347-364.

23. Dole VP. Implications of methadone maintenance for theories of narcoticaddiction. JAMA. 1988;260:3025-3029.

24. Kreek MJ. A personal retrospective and prospective viewpoint. In: ParrinoMW. State Methadone Treatment Guidelines. Treatment ImprovementProtocol (TIP) Series 1. Rockville, MD: U.S. Department of Health andHuman Services; Center for Substance Abuse Treatment;1993:133-143.DHHS Pub# (SMA) 93-1991.

25. Joseph H, Appel P. Historical perspectives and public health issues. In:Parrino MW. State Methadone Treatment Guidelines. TreatmentImprovement Protocol (TIP) Series 1. Rockville, MD: U.S. Department ofHealth and Human Services; Center for Substance Abuse Treatment;1993:11-24 DHHS Pub# (SMA) 93-1991.

26. Stine SM, Greenwald MK, Kosten TR. Pharmacologic therapies for opioidaddiction. In: Graham AW, et al., eds. Principles of Addiction Medicine. 3rded. Chevy Chase, MD: American Society of Addiction Medicine; 2003:735-750.

27. Payte JT, Khuri ET. Principles of methadone dose determination. In: ParrinoMW. State Methadone Treatment Guidelines. Treatment ImprovementProtocol (TIP) Series 1. Rockville, MD: U.S. Department of Health andHuman Services; Center for Substance Abuse Treatment;1993:47-58 DHHSPub# (SMA) 93-1991.

28. Gordon NB. The functional potential of the methadone maintained person.CDRWG Monograph #2. Chemical Dependency Research Working Group:The New York State Office of Alcoholism and Substance Abuse Services.December 1994:43-46.

29. Leavitt SB. Methadone dosing & safety in the treatment of opioid addic-tion. Addiction Treatment Forum [special report]. 2003. Available at:http://www.atforum.com.

30. Federal Register. Opioid drugs in maintenance and detoxification treatmentof opiate addiction; final rule. 2001 (Jan 17);66(11):4085. 42 CFR Part 8.

31. Payte JT, Khuri ET. Treatment duration and patient retention. In: ParrinoMW. State Methadone Treatment Guidelines. Treatment ImprovementProtocol (TIP) Series 1. Rockville, MD: U.S. Department of Health andHuman Services; Center for Substance Abuse Treatment;1993:119-124.DHHS Pub# (SMA) 93-1991.

32. Parrino MW. Overview: current treatment realities and future trends. In:Parrino MW. State Methadone Treatment Guidelines. TreatmentImprovement Protocol (TIP) Series 1. Rockville, MD: U.S. Department ofHealth and Human Services; Center for Substance Abuse Treatment;19931-9. DHHS Pub# (SMA) 93-1991.

33. Public policy statement on methadone treatment. Chevy Chase, MD:American Society of Addiction Medicine; 1991.

34. Rosenblum A, Magura S, Joseph H. Ambivalence toward methadone treat-ment among intravenous drug users. J Psychoactive Drugs. 1991;23(1):21-

35. Methadone treatment survey reveals 56% more patients enrolled inmethadone treatment than previously reported [press release]. New York,NY: American Methadone Treatment Association; April 8, 1999.

36. Data on file, Mallinckrodt Inc., St. Louis, MO.

37. Krantz MJ, Mehler PS. Treating opioid dependence. Growing implicationsfor primary care. Arch Int Med. 2004;164:277-288.

38. Leshner AI. Drug abuse research helps curtail the spread of deadlyinfectious diseases. NIDA Notes. 1999;14(2):3-4. NIH Pub# 99-3478.

39. Ehlers S. U.S. Congress ponders anti-methadone bill [press release].Washington, DC: Drug Policy Foundation; February 19, 1999.

40. Substance abuse parity debate threatens methadone [press release].Providence, RI: PRNewswire; May 24, 1999.

41. Methadone maintenance: some treatment programs are not effective;greater federal oversight needed. Report to the chairman, SelectCommittee on Narcotics Abuse and Control, House of Representatives.Washington, DC: U.S. General Accounting Office; 1990. Pub#GAO/HRD-90-104.

42. McCaffrey BR. Heroin access spurs need for methadone. USA Today.January 25, 1999.

43. D’Aunno T, Pollack HA. Changes in methadone treatment practices; resultsfrom a national panel study, 1988-2000. JAMA. 2002;288(7):850-856.

44. Leavitt SB. Dosage survey 2003: upward trends continue. AddictionTreatment Forum. 2003;12(2). Available at: http//www.atforum.com.

45. Improving quality and oversight of methadone treatment [press release].Washington, DC: Substance Abuse and Mental Health ServicesAdministration, Center for Substance Abuse Treatment; July 22, 1999.

46. Methadone maintenance in private practice. Policies of the House ofDelegates. Chicago, IL: American Medical Association; 1995. Policy No.H-95.957.

47. About Buprenorphine Therapy. Bethesda, MD: Substance Abuse andMental Health Services Administration; 2004.

© 2004 Stewart B. Leavitt, PhDA.T. Forum is made possible by an educational grant from Mallinckrodt Inc.,a manufacturer of methadone & naltrexone. May 2004

is published by: Clinco Communications, Inc.P.O. Box 685Mundelein, IL 60060

ADDICTION TREATMENT