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Methadone Treatment for Opioid Dependence
EDWARD J. KHANTZIAN, M.D.
Am J Psychiatry 2000;157:1895-a-1896. doi:10.1176/appi.ajp.157.11.1895-a
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Haverhill, Mass.

Edited by Eric C. Strain and Maxine L. Stitzer. Baltimore, John Hopkins University Press, 1999, 334 pp., $58.00.

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Opiate dependence is one of the more difficult and devastating drug dependencies to control and overcome. That is the well-known bad news. The less well-known and less appreciated good news is that an effective, albeit not perfect, treatment exists for opioid dependence, namely, methadone treatment.

My introduction to the addiction field dates back three decades to 1970 when we started a methadone maintenance treatment program at the Cambridge Hospital in Cambridge, Mass., for opioid-dependent individuals. This volume on methadone treatment reviews many of the experiences (and frustrations and controversies) we had to learn about "by the seat of our pants" because there was little experience or protocols then to guide us. This book supplies the guides.

The editors, Drs. Strain and Stitzer, and their associates at Johns Hopkins in Baltimore are to be commended for the scope and merit of this volume. Despite multiple authorship, the organization and quality of the chapters are uniformly excellent and there is extensive citation of the literature. After a review of the history of methadone maintenance treatment and regulatory/policy issues, chapters 3–5 review in detail the pharmacology, induction/withdrawal, and maintenance dosing in methadone maintenance treatment. Medical and psychiatric comorbidity issues are reviewed, followed by an excellent chapter that emphasizes the importance and benefits of integrating psychosocial treatments, including family therapies, that we currently employ. The chapter on program organization and operations provides useful guidelines for staffing and for dealing with problem behaviors (e.g., the aggressive patient, drug dealing near the clinic, intoxicated patients, etc.). The final chapters present a comprehensive and insightful review of special treatment issues for women and updates the reader on other medications such as levomethadyl acetate, buprenorphine, clonidine, and lofexidine.

On the basis of their experience and supported by their extensive review of the empirical literature, the Hopkins group provide considerable support for certain fundamentals about methadone maintenance treatment: 1) Methadone maintenance treatment for opioid-dependent individuals is a safe and effective treatment. 2) Effective treatment with methadone is correlated with the administration of an adequate dose of the drug. 3) Methadone detoxification in most cases is not effective in establishing and maintaining abstinence. 4) The medical and psychiatric needs of patients in methadone maintenance treatment are often multiple and complex and require careful evaluation and treatment. 5) The approval and introduction of levomethadyl acetate and buprenorphine show promise of providing alternative agents for treating opioid-dependent individuals.

Notwithstanding these factors supporting the use and efficacy of drug substitution treatments, the authors lament that regulation, stigma, and funding issues conspire to make access to these effective treatments difficult and often impossible. They conclude, "Methadone maintenance treatment, by its nature, is therefore a not favored modality of treatment despite its proven efficacy" (p. 27).

Two aspects of understanding patients in methadone maintenance treatment programs are not sufficiently emphasized in my opinion, namely, the importance of the clinician-patient relationship and the importance of an empathic appreciation of substance abusers’ perceived need for their drugs. The former is first broached in the chapter 7, on comorbid medical disorders, ironically the chapter written by an internist. The latter is important because it strengthens the clinician-patient alliance and improves the prospects for change and establishing abstinence from illicit drugs.

Despite these exceptions, I highly recommend this book as a premier reference for understanding the technicalities and challenges of treating opiate-dependent individuals needing methadone maintenance treatment. It covers all the bases and would be invaluable as a primer for students, trainees, and counselors; for the more seasoned practitioner, it serves as an excellent refresher and reference for all we know and have learned about methadone maintenance treatment for opioid-dependent patients.

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