An expert panel at a National Institutes of Health (NIH) Consensus Development Conference on Effective Medical Treatment of Heroin Addiction has concluded that heroin addiction is a medical disorder that can be effectively treated in methadone treatment programs. The consensus panel strongly recommended expanding access to methadone treatment by eliminating excessive Federal and State regulations and increasing funding for methadone treatment. The conference, which was cosponsored by NIDA, along with the NIH Office of Medical Applications of Research and the NIH Office of Research on Women's Health, was held in Bethesda, Maryland, last November.

Methadone is the medication used most frequently to treat heroin addiction. Outpatient methadone treatment programs administer methadone to reduce patients' cravings for heroin and block its effects, thereby enabling patients to lead productive lives. These programs also may provide counseling, develop vocational skills, and/or provide psychosocial and medical support services to rehabilitate patients. Some patients stay on methadone indefinitely, while others move from methadone to abstinence.

NIH consensus conferences constitute a science forum where a panel of independent nongovernment experts examines the scientific evidence and makes recommendations on an area of medicine. During the course of the conference on treating heroin addiction, the consensus panel, chaired by Dr. Lewis L. Judd of the University of California at San Diego School of Medicine, focused on determining the effectiveness of methadone treatment. After conducting a thorough review of the accumulated data and listening to expert testimony and public debate on the issues, the panel stated unequivocally that addiction to opiate drugs such as heroin is a disease of the brain and a medical disorder that can be effectively treated. Methadone treatment significantly lowers illicit opiate drug use, reduces opiate-related illness and death, reduces crime, and enhances social productivity, the panel concluded.

Despite methadone's effectiveness, less than 20 percent of the estimated 600,000 heroin addicts in the United States are being treated in methadone treatment programs, the panel noted. Many barriers limit the availability of methadone treatment.

These barriers include unnecessary laws administered by a number of Federal agencies and many State and local governments that burden treatment programs with excessive regulatory requirements and duplicative inspections. Some of these regulations restrict treatment programs' ability to tailor methadone doses to the needs of individual patients. Other regulations require physicians to obtain a special Federal registration to use methadone to treat narcotic addiction, thus limiting the number of physicians who are available to treat heroin addiction. Wider use of methadone treatment also is restricted by a shortage of physicians and other health care professionals who are trained to treat heroin addiction, and inadequate funding to provide methadone treatment slots for all those who require them.

The panel recommended a number of steps to improve access to methadone treatment for all people addicted to heroin and other opiate drugs. The panel's recommendations include the following:

• eliminating unnecessary layers of Federal and State regulation for methadone and similar opiate treatment medications;
• instituting means other than regulation to improve the quality of methadone treatment, such as accreditation of methadone treatment programs;
• improving the training that physicians and other health care professionals receive in the diagnosis and treatment of patients with heroin addiction; and
• increasing funding for methadone treatment, including providing benefits for methadone treatment as part of public and private health insurance programs.

The panel also recommended that additional research be conducted on factors that lead to heroin use; changes in the brain that occur with repeated heroin use and result in addiction; the neurobiological processes of craving; and the differences among individuals who are able to end opiate addiction and those who cannot. In addition, the panel called for a national study to assess the prevalence of heroin addiction in the United States and for rigorous studies of the financial costs of heroin addiction to society and the cost-effectiveness of methadone treatment.

...one of the most successful treatments for heroin addiction...

Even when we provide addiction treatment, we often erect barriers around it. The state of methadone treatment for heroin addiction is an example of how government policy collides with a goal of positive public health outcomes when it comes to dealing with drug addiction.

Untreated heroin addiction and its link to crime and illness cost society some $20 billion a year, according to the National Institutes of Health. The estimated cost of treating hepatitis B and C, AIDS, and other illnesses linked to dirty needles and heroin addiction accounts for $1.2 billion of that total. Heroin is also one of the hardest drugs to quit "cold turkey" and for good.

Methadone maintenance is a replacement therapy in which heroin addicts take regular doses of the long-acting methadone, a synthetic opiate, to quell withdrawal and cravings that would otherwise drive them back to heroin use. It is one of the most successful treatments for heroin addiction. "For IV drug users, injecting opiates and at significant risk of AIDS . . . who can't or won't give up that opiate effect, [methadone] is a tremendous public health benefit," says A. Thomas McLellan, a researcher at the University of Pennsylvania. A 1994 study of drug treatment in California found that methadone maintenance clients achieved greater reductions in illegal drug use, criminal activity, and hospitalization than addicts in any other kind of drug treatment.

Methadone treatment is also highly cost-effective. According to the New York Academy of Medicine, the lifetime Medicaid cost for each injecting drug user with AIDS is about $109,000. In contrast, one year of methadone treatment costs about $5,000 per patient.

But there are many obstacles in the way of heroin addicts who seek methadone treatment. The dispensing of methadone is rigidly regulated. Only a handful of physicians in the U.S. are registered to provide methadone treatment in their practices today, since, to dispense the drug and be approved for treatment, physicians have to make a special application to the FDA and the DEA. The Department of Health & Human Services and the FDA also decide dosage regimens and how, and under what circumstances, methadone maintenance may be used to treat opiate addiction. Most methadone is dispensed from clinics that must obtain an extra license and comply with a mountain of both federal and state regulations.

The result is that, for many heroin addicts, getting methadone treatment is a tremendous burden. There are approximately 737 active methadone clinic programs in the U.S., according to the FDA. Although programs vary with regard to methadone dosing and take-home policies, most dispense medication as well as provide counseling and other medical services. But many states don't allow methadone clinics, forcing some patients to drive hundreds of miles each day to get their required daily dosage. Idaho, Mississippi, Montana, New Hampshire, North Dakota, South Dakota, West Virginia, and Vermont don't allow methadone clinics. Clinics in states that do allow methadone often have strict morning hours that make it difficult for patients to stick to the regimen. One heroin addict featured in a 1997 New York Times article said he traveled four hours round-trip every day to swallow his methadone and produce a urine sample -- a process that takes five minutes. He described his quest to stay off heroin as a sometimes "white-knuckle experience" because he has to travel during snowy and icy New England winters to arrive at the clinic by 9 a.m. and return home to begin work.

Heroin addicts in Athens, Ohio, also have to travel long distances if they want methadone. The closest methadone clinic to Athens is Columbus, Ohio, 74 miles away. Betty Woellner, a drug and alcohol counselor with Health Recovery Services, Inc., in Athens, agrees that laws need to be changed to make access to methadone easier but she says changing the public's attitude toward heroin addiction is an important first step. Woellner says the public remains undecided over whether addiction is a disease or a moral failure and the fear of opiate addicts creates an unwillingness to spend treatment dollars on them. Many members of the public fear the consequences of opening new methadone clinics in their communities. "There is a lot of old historic judgment about heroin addiction," says Woellner. "But it is a myth that anyone will go on methadone for fun. These are people who truly are desperate and can't get through the day without heroin."

Every day some 115,000 Americans take the prescribed drug methadone, a synthetic opiate, used as maintenance treatment for heroin addiction. Studies find that two-thirds of methadone patients show dramatically decreased drug use, decreased criminal involvement, and improved life circumstances.

Heroin is one of the hardest addictive drugs to "kick" for good. It provides a euphoric rush, and chronic heroin users can experience intense cravings for more of the drug even years after last use.

Methadone can help with these problems. It is also an opiate, but because methadone is taken orally, it does not provide a euphoric rush. It is long-acting, so the patient no longer experiences the extreme ups and downs that accompanied the waxing and waning of heroin blood levels. Furthermore, because methadone actually blocks the "high" from any heroin use, a patient on it has little motivation to use heroin again. Essentially, the patient remains physically dependent on an opiate, but is freed from the compulsive, uncontrolled, and disruptive use seen in heroin addiction.

Still, misconceptions abound and continue to limit methadone's availability. Neighborhood groups often oppose a new clinic because they assume it will lead to higher rates of drug use and crime (studies show these rates actually go down). And those favoring a "drug-free" approach often dismiss methadone maintenance as merely "substituting one drug for another."