Substitution Therapy for Heroin Addicts

Substitution therapy is an alternate form of a substance medically administered to an addict who is dependent on the illicit drug. Often times this treatment is used in aiding those with opioid addiction, namely heroin. The drugs that are used in these management procedures, namely methadone, buprenorphine and suboxone, are similar pharmacologically to heroin in that they have comparable mechanisms of action on the brain and its opioid receptors. The therapeutic process engages in the drugs’ demonstrating their effects in a way that reduce cravings, the emergence of withdrawal symptoms, and the pleasurable effects associated with heroin. While the benefits of treatment seem appealing, there is concern about the costly effects of substitution therapy as well as a moral confrontation where some claim that those in this treatment are still essentially abusing a drug. A low level of compliance among heroin users also presents a disadvantage. Beneficially however, it is undisputable that substitution treatment can be highly effective for stopping heroin use and may actually be considered cost effective when compared to money lost to the crime as a result of the drug. There are considerable advantages when looking at the treatment from a harm reduction standpoint also considering that oral administration of an alternative drug is much safer than intravenous use with dirty needles. Exploring whether the costs outweigh the benefits or vice versa regarding substitution therapy leads mainly to the conclusion that, for most heroin users, it is a means to an end. Although some enroll in a maintenance program as an end in itself, substitution is an effective therapy which increases the quality of life of most patients.

Heroin: General Information

Prevalence of Use

While the abuse liability of heroin is a serious concern in and of itself, it is fortunately not too widely abused in comparison with the prevalence rates of use for other illicit drugs. Still alarming however are the statistics on use as according to the 2008 National Survey on Drug Use and Health (2008) which indicates that 213,000 people aged twelve and older reported past month use, and 453,000 said they used in the past year. Considering the drug’s high level of tolerance and intense pleasurable associations associated with taking it, the mortality rate is high in instances of overdose. While the prevalence is relatively small within the large scope illicit drug abuse prevalence in total, the statistics are especially disturbing when considering the occurrence of diseases as a result of using dirty hypodermic needles, including HIV and hepatitis’ B and C.

Heroin: Mechanism of Action

As an opiate drug, Heroin is abused for its pleasurable and pain relieving effects. Acting as a powerful agonist at the mu receptor in the brain, the presence of heroin (which is converted to morphine at the receptor) (CNSforum, 2005), actually inhibits the release of GABA on dopaminergic neurons. This results in increased stores of dopamine which ultimately leads to feelings of euphoria associated with heroin use. After the initial pleasure stage, users report falling into the “nod,” described as a semiconscious state. Many receptors to which heroin binds is located in the brainstem, the area that controls a majority of the body’s automatic processes. Therefore, overdoses are often fatal.

Common Substitution Drugs

Methadone

Methadone, one of the most commonly used maintenance alternatives for heroin addicts seeking treatment, has a similar pharmacological mechanism of action as heroin and morphine. It is also an agonist at the mu receptor and affects the release of dopamine, norepinephrine, and acetylcholine (NCBI, 2000). Its influence on these neurotransmitters aid in the drug’s analgesic effects and ultimately result in craving reduction, less intense euphoric effects, and a shortening of withdrawal symptoms. Heroin addicts undergoing methadone maintenance therapy (MMT) often take one daily dosage which hinders withdrawal symptoms for upwards of 24 hours.

Buprenorphine

Buprenorphine is a partial agonist and thus only exhibits minimal effects compared those of a full agonist. It has a high affinity for binding at the mu receptor and disassociates from the site slowly (Mello & Mendelson, 1980). It has a longer duration of action than Methadone, but the pleasurable effects of buprenorphine are minimized in comparison to the other drug. Buprenorphine is also an antagonist at the kappa-opioid receptor, aiding in hyperpolarization and reduction of firing in neurons in this area. Heroin addicts being treated with buprenorphine can sometimes go every other day without an administration because of its long-lasting effects. It has a high safety profile and is often preferred over methadone for some patients.

Suboxone

Suboxone is a combination of the partial agonist drug buprenorphine and the opioid antagonist naloxone. Buprenorphine’s agonistic effects allow for a reduction in withdrawal symptoms with a milder form of euphoria associated with heroin use. If taken orally, a short amount of naloxone actually reaches the brain and the user only feels the effects of the buprenorphine (www.aboutsuboxone.com); however, if the user injects the drug intravenously, then the naloxone component actually causes intense withdrawal symptoms. Suboxone is therefore essentially used as a therapeutic substitution treatment, but is also an effective mechanism is inhibiting the behavioral action of needle-injecting as well.

Disadvantages of Substitution Therapy

High Cost Associated with Implementing Treatment

While substitution therapy seems mainly beneficial in the scope of being an effective method of treatment, it has the drawback of being costly. For methadone maintenance treatment (MMT), the statistics indicate that it took an average of at least $4,000 per year to keep a patient on the drug in 1997 (Simpson, 1997). Newton (2009) now reports that heroin substitution treatment can cost upwards of $22,000. These numbers, coupled with the threat of noncompliance and low retention rates allow critics to argue that taxpayer dollars should not be spent on maintaining these treatments. Barnett (2009) concludes that the implementation of buprenorphine is highly expensive, costing upwards of $200 per month per user. Even more controversial, modern economic hardships allow some to argue that money need not be spent on those people who display the socially unaccepted behavior of drug use anyway. The statistics on heroin as a whole are low, so it may even be considered that the high amount of money used on substitution therapies should be used towards treatment approaches for drugs that are more widely abused. It is questionable whether maintenance treatments are even a means to an end; after all, not all patients who undergo methadone or buprenorphine treatments remain faithful to their heroin abstinence. In this instance, would the money used to put addicts through such therapies be essentially lost for no beneficial reason? This question remains subjective; some could argue that the cost to put the relapsed patient through therapy was for no good purpose, but others would claim that treatment always holds some kind of benefit even if it is minute.

Moral Objectivity: Addicts are Still Dependent on Drugs

An argument against the use of substitution therapy is that it allows the heroin user to remain dependent on a drug that produces effects similar to heroin itself. Therefore the patient is still dependent on drugs because he simply substitutes one drug for another. While the euphoric effects are not as intense, they do still exist, and the user gains satisfaction and reinforcement from taking the substitute. Some critics arguably assume that the goal of treatment should be abstinence. This is not actually always the case for those users who may use substitution therapy as a means of harm reduction only. Whether treatment should be considered as resulting in complete abstinence from heroin or reducing most of the negative effects associated with regular use is subjective. However, opponents of substitution often argue that it would not be considered a treatment because it does not actually “treat” addiction completely and even has the ability to develop dependence to the therapeutic drugs (Jarvinen, 2008). Methadone has a high abuse potential in itself; it is even used a street drug often times for a high that is less costly and pleasurable effects that are similar to heroin. Methadone maintenance is therefore sometimes questioned as to whether it is actually treatment at all. Furthermore, even methadone has a negative stigma associated with it and the people who use it, so many communities are not often compliant with building heroin treatment clinics.

Low Compliance Rates

If disregarding the mentioned disadvantages, the benefits of treatment seem pleasant enough that some would question the reason as to why all heroin addicts do not seek some form of substitution therapy. Simply put, many abusers do not want to give up their habit. It is common for patients undergoing maintenance treatment to either relapse after its conclusion or even use heroin again during treatment which sometimes results in dismissal of the program (Weiss, 2004). Methadone and buprenorphine only exert minimal effects compared to heroin, and the absence of that full euphoria can cause many to relapse even if the medication is successful at hindering withdrawal symptoms and cravings. Furthermore they have longer durations of action of the less intense effects so it is overwhelming for some users to go so long without the intense rush that heroin is capable of giving. Every addict has his reason for not wanting to undergo opioid replacement therapy, and there are many possibilities for non adherence to treatment programs. Often times addicts are fearful of potential side effects and withdrawal symptoms, or they do not have adequate support systems to encourage them to quit (Weiss, 2004). Some also refuse to accept the reality that they even need assistance in relinquishing their habit.

Benefits of Substitution Treatment

Effective at Stopping Heroin Use

Even though there are obvious disadvantages to substitution therapy, it is undisputable that it is effective in helping many users stop taking heroin altogether. Although some do relapse, there is also a high success rate for those being treated with any substitution alternative. Compliance issues aside, those who undergo treatment with suboxone are successful because of the drug’s ability to prevent abuse. Withdrawal symptoms persists if an addicts attempt to inject Suboxone, so its abuse liability is low and may work more efficiently in stopping heroin use. Mello and Mendelson (1980) performed a series of studies on heroin addicts and the prevalence of heroin self administration when given buprenorphine. Compared to control subjects who self administered 100% of available heroin when given a placebo, those given buprenorphine only administered 2-4% the heroin available. Buprenorphine has shown not only to be effective in stopping heroin use, but it does not induce physical dependence as well (Jasinski, Pevnick, Griffith, 1978). Unlike methadone maintenance treatment which often times causes high tolerance among users and has its own abuse potential, buprenorphine is becoming increasingly accepted as highly effective in reducing heroin use.

Harm Reduction

Considering that all forms of substitution therapy involve orally administering the drug, it is better for an addict to be taking an alternative substance rather than injecting heroin with potentially dirty needles. This form of maintenance could be supported by a harm reduction approach because while addicts must continue to take a pharmacologically similar drug to heroin, it is at least better to administer a different, less effective form in a clinical setting rather than shooting up on street drugs. Oral administration allows for smaller effects in a safer way, and when addicts discontinue using dirty needles the threat of HIV and hepatitis’ B and C decline dramatically (Eissenberg, Johnson, Bigelow, Bigelow, Walsh, Sharon 1997). Not only is administering alternative forms of heroin more efficient in that regard, but users often report a more satisfying quality of life in treatment as well. Patients using buprenorphine often do not have to be in a medical setting and are usually able to remain highly functioning while on the drug. Most are able to go to school, have a job, and remain active with their social and family lives without the hindrance of worry about the next heroin fix. It has been found that employment among patients in methadone maintenance programs is 40 to 80%, and there is an 85% decrease in the criminal activities of these patients as well (Stine, 1997). They are normally not engaging in the same illicit activity they once were, increasing even their safety from the harsh conditions associated with buying from street drug criminals. This is also leads to decreases in prostitution and hustling activities associated with obtaining heroin.

Decline in Criminal Incarceration Linked to Heroin Use

When one takes a medically prescribed substitution medication, they are often times no longer involved with criminally obtaining heroin illegally. It is more beneficial to aid in the treatment of the source linked to an addict’s incarceration rather than put them in jail where they will likely continue using heroin upon release. Statistics indicate that it is actually more expensive to keep one incarcerated rather than treating them with substitution therapy (Newton, 2009). The Bureau of Justice Statistics report that there were roughly 1,841,200 drug abuse related arrests in 2007 (BJS, 2007). Furthermore, keeping an addict out of jail and active in treatment gives them the opportunity to undergo counseling or behavior modification which only increases the chance of success. Heroin addicts are not only arrested for using the drug itself, but from activities such as stealing they do to obtain money. As it becomes a vicious cycle for the user to find money to support an everyday habit, he ends up inflicting serious consequences on family, friends, and essentially everyone he comes in contact with. In that regard, the decrease in criminal activity associated with keeping addicts off of the street helps the general well being of a community. Violence associated with the selling of heroin is not as prominent, and other harsh problems can effectively be solved.

Higher Significance of Benefits Versus Disadvantages

The Benefits of Substitution Therapy Outweigh the Costs

While there are obvious disadvantages that arise with substitution treatment, the positive effects it has on the heroin addict and to society in general are more significant. There are moral implications considering that the user still remains dependent on drugs, but providing the alternatives in a clinical setting and improving the quality of life overall for the user is much more beneficial than remaining addicted to heroin or being incarcerated. There is essentially nothing therapeutic about being in jail for the drug addiction and it is likely that the user will continue to use heroin when he is released. The price for keeping somebody in prison is much more expensive to the taxpayer than maintenance treatment anyway, so it is logical retain more money while genuinely helping the addict in the process. The user’s habit affects those he surrounds himself with; most heroin addicts lie to and steal from friends and family members to obtain money for the next fix. The ability of the alternative drugs’ to lessen cravings and avoid withdrawal allow heroin users to gradually take themselves off of the drug. The benefits associated with oral versus intravenous administration are many and have proven to reduce the risk of blood-transmitted diseases also. If a user is truly willing to comply with the alternative methods and leave the hardcore drug lifestyle, substitution therapy can be highly efficient in stopping heroin use.

A Means to an End

Substitution treatment is a means to end, but not an end in itself and the practice should not be discontinued. Although addicts normally remain in treatment for extended periods of time, there are success rate statistics of many users who stop drug use altogether. The goal of the treatment is to essentially stop heroin addicts from using the drug especially with regards to injecting it intravenously. The process should not stop there however. The ultimate end result would ideally be abstinence altogether, but this should not be rushed. All heroin addicts are different in how they view their dependence and everyone has different goals for themselves when they begin substitution therapy. For some, the road to complete recovery may only last for a few months with the alternative drug whereas the dosage may then get continuously smaller until full abstinence is achieved. Others may have more a more difficult time coping with the less pleasurable effects they are receiving and even the change in lifestyle for those who are use to chasing money for heroin every day. The therapy must remain an end in itself for some users, especially those in methadone maintenance treatment programs. Even if this is the case however, methadone use normally results in a more positive quality of life than remaining addicted to heroin. As long as the addict must no longer illegally go about obtaining heroin from street drug users, he is able to improve upon his life and himself.

A controversial treatment that keeps critic divided on the significance of its benefits over its disadvantages, substitution therapy is positively effective for opioid dependence. When exploring the pros and cons of undergoing the financial burden of implementing these programs, the long term benefits are more significant than discontinuing them. Substitution treatment has aided in helping many heroin users discontinue the habit while helping them improve their quality of life. Maintenance treatments are not 100% effective and often times take months to years before a person comes off of drugs, the improvement for the addict’s general well being is undisputable. The end result would ideally be abstinence from drugs altogether, and this treatment is a beneficial and effective way for an addict to start the process of stopping.