Substitution maintenance therapy (SMT) is the world’s recognized and most cost-effective method of treating people with mental and behavioral disorders due to opioid use.
Methadone hydrochloride and buprenorphine hydrochloride are commonly used for SMT. However, in some countries, medical heroin or a combination of buprenorphine and naloxone may be used.
The inclusion of methadone and buprenorphine in the list of essential drugs indicates the proven effectiveness and safety of these drugs. That is why if you google “methadone clinics near me” (AddictionResource provides info) there will be a lot of results in most of the countries.
In 2005, the World Health Organization (WHO) added both drugs to its Model List of Essential Medicines, and in 2009 it issued guidelines recommending that all countries make SMT the guidelines of treatment for people addicted to opioids.
Methadone is an oral slow-acting opioid agonist, so it gradually enters the brain, with minimal effect of euphoria that occurs after administration by other routes, while preventing withdrawal symptoms.
Buprenorphine is a partial agonist and is characterized by both agonistic (similar to opiates) and antagonistic (blocking the action of opioids) activity against opioid receptors. The use of buprenorphine for SMT allows patients who are in the opioid withdrawal stage to minimize withdrawal symptoms. In addition, when taken regularly as a maintenance drug, buprenorphine usually reduces the craving for illicit opioids in people who are physically dependent on opioids.
Treatment of opioid addicts in subutex or methadone clinics with SMT has a long history. Thus, methadone has been used in the world since 1960, buprenorphine – since 1976. For a long time, many studies have been conducted to evaluate the effectiveness of this type of treatment.
It is proved that participation in the SMT program has significant benefits both for the patient and for society as a whole, as it allows:
- reduce the use of illicit opioids;
- reduce crime, in particular the need to raise funds for the purchase of illegal drugs;
- reduce mortality from overdose and premature mortality associated with drug use (cardiovascular disease, sepsis, etc.);
- improve social functioning (employment, reconnection, parental responsibilities, etc.);
- reduce risky behaviors associated with the spread of HIV, hepatitis B and C among injecting drug users, improve prevention of mother-to-child transmission of HIV;
- create conditions for effective treatment of AIDS, TB and comorbidities (sepsis, purulent infections, hepatitis B and C, trophic ulcers, phlebitis);
- improve the somatic health of patients.
In countries where the HIV / AIDS epidemic is spread primarily through injecting drug use, the main factor that may influence its cessation is the treatment of drug addiction with the use of SMT drugs.
Conditions for the effectiveness of SMT
SMT is one of the most effective treatments for people with mental and behavioral disorders due to opioid use. There are certain factors that influence effectiveness of the program:
- the correctness of the drug (diagnosis (ICD-10) “opioid dependence syndrome”);
- the correctness of the prescribed dose (taking into account individual needs, adherence to the principle of prescribing low initial doses and high maintenance, compliance with recommendations for therapeutically effective doses);
- continuous and long-term treatment (no restrictions on the duration of treatment, including the possibility of lifelong treatment, given the understanding of dependence not as an acute condition, but as a chronic disease);
- combination of psychosocial support measures with pharmacological treatment with;
- availability of treatment for comorbid conditions (links to HIV, TB services, integration of services, etc.).
SMT not only does prevent HIV infection but also increases adherence to HIV treatment, reduces the risk of hepatitis C infection, and reduces the risk of overdose. Many injecting drug users usually gain access to health care services after coming into contact with health care providers through SMT programs.
Economic effect of treatment and non-treatment of opioid dependence
Probably due to the ambiguous attitude of society to the appointment of drug addicts, none of the methods of treatment has been studied so carefully. Many studies have been conducted using a variety of methods. The effectiveness of SMT was compared with various other treatments and different variants of SMT programs themselves.
In 1991, a comparative analysis of two groups of people waiting in line for a major SMT program was conducted in New York. One group received methadone, the other did not receive any therapeutic assistance. The number of people who received methadone and stopped using heroin was three times higher than the number of those who quit heroin from the second group.
Three special studies were conducted in the United States, Hong Kong, and Sweden, where the effectiveness of methadone therapy was evaluated by comparing the health status of those who used methadone with those who did not use the drug, ie, with the behavior of control members who did not receive no therapy.
After a year of follow-up, it was found that those who were not treated were 97 times more likely to use heroin and 53 times more likely to go to prison than those who were treated.
Numerous studies of different SMT variants have been organized. The results can be reduced to a few basic points.
- Supportive SMT programs are significantly effective in reducing the incidence of illicit drug use, criminal activity and mortality among IDUs (including overdoses), as well as in reducing HIV infection.
- Long-term treatment is more effective than short-term courses.
- Low doses of methadone lead to an increased risk of illicit drug use and relapse.
- Programs that combine SMT with a wide range of additional services (social assistance, help of a psychologist, counseling of other specialists, easier access to other types of medical and social assistance) are more effective.
- Retention of clients in the program of maintenance therapy with methadone – 60-70%, which is much more than the same indicator in non-narcotic forms of rehabilitation (drug free programs).
- Supportive care is significantly more attractive to most IDUs than existing rehabilitation programs based on a different approach.
- SMT demonstrates significant cost-effectiveness that surpasses all other treatments. This makes it more accessible to the maximum number of IDUs, even in countries with limited resources. The cost of the drug is extremely low. For example, the cost of methadone per year of treatment in most of the methadone clinics for one patient can be $ 60-80 per year.
However, SMT has its limitations. First of all, today it is suitable only for opiate users and is ineffective in case of dependence on other drugs (cocaine, amphetamines, hallucinogens, barbiturates).
It does not save the patient from opioid syndrome, but only modifies the syndrome so that most of the negative effects of illicit drug use can be minimized.