Learning about opioid agonist therapy
What’s an opiate, what’s an opioid?
The term “opiate” refers to drugs derived from the opium poppy, such as opium, morphine and codeine, and to drugs that are derived from the opium poppy and then chemically altered, such as heroin. The term “opioid” is like a family name that includes opiates, and also other drugs that have morphine-like effects, but are not made from the opium poppy. These drugs are made by chemists in labs. Pain medications containing hydromorphone, fentanyl or oxycodone (e.g., Duragesic, OxyNeo, Percocet, Dilaudid) are examples of chemically manufactured opioids; methadone and buprenorphine also belong to this group.
Your body produces its own opioid drugs, called endorphins. Endorphins are your body’s natural painkillers.
Inside your brain is a number of what are called “pain receptors.” Their job is to tell you when pain is happening in your body. For example, if someone steps on your toe, your pain receptors light up and you cry “Ow.”
At first the pain is quite intense, but by the time the toe stepper is telling you how sorry he or she is, it doesn’t hurt quite so much. While your pain receptors have told you to feel pain, they are also signaling to your endorphins to come and relieve the pain. The endorphins “fill up” your pain receptors, so in a few minutes the pain in your toe seems trivial.
Endorphins can boost your mood too, and affect how you respond to situations of stress. Exercise is a great way to release endorphins.
What happens if you fall and break your arm? Your body won’t produce enough endorphins to knock out that much pain. Inside your brain many of your pain receptors are still empty, and they’re screaming out to be filled with something to take away the pain.
In situations like this, it’s fortunate that opioid drugs can fill up the pain receptors in the same way as endorphins. What’s more, the strength of the opioid drug and the dose can be adjusted to address the intensity of pain, as needed. You might be moaning when you get to the hospital, but once your doctor gives you a shot of morphine, you can be reasonably comfortable while he or she sets your broken arm and puts it in a cast. Before you go home, you are given a prescription for codeine pills, so you won’t have to suffer while the arm gets better.
For many people, a situation like this would be the only time they take opioid drugs. Once the arm begins to heal and the pain becomes tolerable, they stop taking the codeine, and don’t give it a second thought.
Opioid dependence and addiction
But what if the pain doesn’t go away? What if the only thing that can bring relief is opioid drugs? You might continue to take them, and if you like the way they make you feel, you get some more.
After a while, your body adapts to the presence of the drug. You find that if you don’t take the drug, you feel sick. You may also notice that the good feeling the opioids bring is not coming on as strong as it was. This is what is called physical dependence. Many people who take opioids for pain will develop physical dependence.
Physical dependence in itself is not the same as addiction. You know you are becoming addicted when you take more at a time to get that feeling, or you try a stronger opioid, or you continue to take opioids simply to avoid withdrawal. You think you can stop when you want to, but when you do try to stop, you can’t stop thinking about starting up again. Eventually, much of your time, energy and interest are absorbed in getting and taking drugs. You feel like you have to have them.
An opioid addiction can begin in a variety of ways. Some people start out using opioids to manage pain. Some try it out, seeking out a new experience and finding one that is pleasurable and predictable for a while. Some are seeking relief from the daily grind of poverty, from emotional hardship or from depression.
Once people get into it, they may go on using for a long time, even though they know that it’s dangerous, and that the pleasures are short-lived and superficial. They know the drugs keep them away from people and things that matter to them.
Some stop using drugs on their own. Some find that counselling and group therapy give them the support they need to stop. Some try to stop again and again and keep on going back. Their health, home, finances and relationships may slip into a state of chaos. They need a chance to put the struggle with the drugs aside and take the time to sort out their lives.
Here’s where opioid agonist therapy (OAT) can help.
Once the snowball starts, you don’t really see it until the storm is there, and then the storm is so thick, there’s no vision. You don’t see anyone, you don’t see anything, you don’t know where to turn and you kind of fall within yourself and you lose yourself. You don’t know who you are anymore. It’s important to me to try to explain, because unless you’ve lived through it, it’s very hard to understand.
Ann, 42 | Methadone, 2 years, 5 years
Prior to methadone, there was a cycle—find money, find someone to get a pill off of, do the pill, and then three hours later, decide whether to get high again or to feel sick. It’s a very time-consuming cycle, there’s no time for anything else. Not to mention crime—I ended up breaking the law to find the money. Since I started on methadone, my life has done a total 180-degree turn. I’m employed, I’m clean, I have my daughter back: I have relationships with trust.
Shaun, 36 | Methadone, 4 years
How opioid agonist therapy works
Methadone and buprenorphine are used to replace the opioid drugs you’ve been taking. They fill up the same receptors in your brain as other opioid drugs. This works to prevent withdrawal and reduce craving. While methadone and buprenorphine can be used to relieve pain, they are most noted for their role in stabilizing the lives of people who are addicted to opioid drugs.
Many other opioids, such as morphine, oxycodone and heroin, are “short acting.” This means that people who are opioid dependent will experience withdrawal symptoms only a few hours after using. Because methadone and buprenorphine are “long acting,” they can prevent withdrawal for 24 to 36 hours. Once you’re on a stable dose of OAT, you should feel “normal,” and be able to focus your life on things other than drugs.
Another way OAT works is that it can “block the high” of other opioid drugs. If you take other opioids, you can die of an overdose, but you may not get high. Keep this is mind. It may save your life. Taking other opioids on top of methadone or buprenorphine is extremely dangerous.
The history of methadone and opioid agonist treatment
Methadone was first discovered in Germany before the Second World War. When the Allied forces cut off the supply of morphine to Germany, the Germans manufactured methadone as a painkiller. After the war, the Americans seized the formula.
Methadone’s first role as a treatment for opioid addiction was to ease the process of withdrawal.
The potential of methadone as a treatment for people who are addicted to opioids was recognized during a study conducted by Drs. Marie Nyswander and Vincent P. Dole in New York in the 1960s. The study involved two people with a chronic opioid addiction and long criminal records related to their addiction. The doctors hoped to show that when study participants were given enough drugs to satisfy their craving and keep them free of withdrawal, they would no longer commit crimes, and they’d become interested in other things.
Study participants were given frequent doses of morphine to keep them comfortable. Sure enough, they showed no interest in crime or other drugs. However, other than watching a bit of TV, they showed little interest in anything. All they did all day was relax on the couch, either nodding off or asking for their next shot.
Nyswander and Dole were ready to declare their experiment a failure. To prepare their study participants for withdrawal, they put them on methadone, intending to taper down the dose. To everyone’s surprise, once on methadone, the participants perked up, showed little desire for drugs and began to talk of other interests. One asked if he might be given some paints so that he could renew his love of painting. The other asked if he might go back to school. The doctors had found what they were looking for! With an adequate dose of methadone, their study participants were comfortable, clear-headed and able to renew their lives.
. . . you can’t ask most drug addicts to stop and consider what vocation they want to go into, or to evaluate anything, so long as their primary preoccupation is to get drugs. When an addict no longer has to worry compulsively about his source of supply, then he can concentrate on other things. At that point, rehabilitation can become a meaningful word.
— Dr. Marie Nyswander1
Opioid agonist therapy in Ontario
In 1996, there were 650 clients receiving methadone maintenance treatment in Ontario; as of July, 2015, there were more than 42,000. This dramatic increase is partly due to the rise in prescription opioid addiction in Ontario. It also reflects the trend in public health policy to reduce the damage of opioid use. An early sign of this trend, known as “harm reduction,” was the sprouting up of neighbourhood needle exchanges aimed at controlling the spread of HIV and other infections.
Prior to 1996, methadone treatment had been available in Ontario for many years, but there were few doctors authorized to prescribe it, and few specialized clinics to dispense it. Even if you were an ideal candidate for methadone treatment, and you were eager to get started, it might take years before you could begin. Unable to get quick access to effective treatment, people were contracting life-threatening diseases from sharing needles, and dying from overdose at an alarming rate.
In response, new guidelines for the use of methadone as a treatment of patients with opioid addiction were made available to doctors and pharmacists. The number of physicians able to prescribe methadone increased, as did the number of pharmacies ready to dispense methadone.
In some communities in Ontario, it is now possible to have an opioid addiction assessment and to start OAT on the same day. Most clients take their dose at their local pharmacy and see a doctor at a specialized OAT clinic. In future, it is hoped that more family doctors will provide the therapy, making OAT more accessible to their patients.
Buprenorphine-naloxone (Suboxone) became available for the treatment of opioid addiction in Canada in 2007.
OAT took me off of the rollercoaster of taking pain medication to numb emotional pain, running out of it, ending up in withdrawal and feeling absolutely horribly ill. It has given me balance in my life and has helped to provide me with the mood stability that I needed in order to engage in counselling to learn to identify and cope with emotions more effectively.
Jessica, 36 | Methadone and
buprenorphine, 3 years
I was a mover. I did a lot of pills, for the pain and the work, and I liked it too. I went on methadone ’cause I didn’t want to get sick. It got me off my addiction.
Paul, 57 | Methadone, 4 years
Methadone will work if you are serious about making changes in your life. While taking methadone, you can go back to work and build healthy relationships and become a productive member of society. When you wake up in the a.m. you will be able to look at yourself in the mirror and know that you are on the right path.
Shaun, 36 | Methadone, 4 years
1 Quoted in A Doctor among the Addicts, by Nat Hentoff, Rand McNally, 1968