Heroin dependence - medication treatments

Medication treatments (pharmacotherapies) for heroin or other opioid dependence include methadone, buprenorphine and naltrexone.

Before someone starts a treatment program for drug dependence, it is important that they understand what is involved. A doctor experienced in drug treatment, or a drug counselor, can explain the process. An approved prescriber can prescribe a regular dose of methadone or buprenorphine for a person who is dependent on heroin.

Methadone#

Methadone is an opioid that remains active in the body for longer than heroin. Its effects last about 24 hours, with peak effects felt 4 to 8 hours after a dose. Because of this, only a single daily dose is usually needed, which allows a person to stay stable while making other positive changes in their life.

Methadone also reduces risky behaviors such as injecting and costs less than buying heroin or other illicit opioids. Treatment can be long-term (months or years) to reduce the risks of using illicit drugs, or short-term (two weeks or less) to help a person safely withdraw from heroin.

It is usually taken as a syrup that is drunk, but is also available in injectable and tablet form (the tablet is more common when prescribed for pain relief).

Effects and side effects#

Methadone does not give the same euphoric sensation (“high”) as heroin, but it has some similar effects and prevents withdrawal symptoms. Effects can include feelings of general wellbeing, reduced blood pressure and a slower heart rate.

Methadone can also cause unpleasant side effects, though adjusting the dose may help. Possible side effects include:

• drowsiness, dizziness, nausea and vomiting
• sweating, constipation and skin rashes
• heart palpitations
• tooth decay, because methadone (like heroin and other opioids) reduces saliva in the mouth
• menstrual changes and reduced sex drive

Good oral hygiene can help reduce tooth decay.

Some side effects are caused by taking other drugs or medications at the same time, such as alcohol or benzodiazepines (tranquillisers). Mixing methadone with other depressant drugs can have serious effects, including death, so it is best to avoid combining it with:

• alcohol
• heroin and other opioids
• sedatives, tranquillisers and sleeping pills (benzodiazepines)
• other prescribed pain relievers
• any other type of depressant drug

If the dose is too high, methadone can cause lowered blood pressure, dizziness and shallow breathing. If the dose is too low, withdrawal symptoms can occur. These symptoms usually begin around days 1 to 3 and peak at about day 6, and can include difficulty sleeping, aggression, irritability, abdominal cramps, tremors, spasms and drug cravings.

Methadone does not suit everyone#

Some people may be better suited to buprenorphine, or to other approaches such as detoxification and residential rehabilitation. Methadone is not only used to treat opioid dependence; specialist pain doctors sometimes prescribe it for certain chronic pain conditions, usually in tablet form.

Buprenorphine#

Buprenorphine is a partial opioid agonist. This means it still produces opioid effects, but they are not as strong as those of a full agonist like methadone. It also has a ceiling effect, where its effects are “maxed out” and do not get stronger even if more is taken.

Two common formulations are a buprenorphine and naloxone film placed under the tongue, and a buprenorphine-only tablet. Characteristics of buprenorphine include:

• It is effective in managing the symptoms of heroin withdrawal.
• On its own, it is less likely to cause overdose than methadone.
• Only one daily dose (or less) is needed, due to its long-lasting effects.
• A short course can help a person withdraw from a methadone maintenance program.

Long-acting injectable buprenorphine is also available for some patients, with injections given weekly or monthly depending on individual needs. This helps with some of the challenges of having to attend a pharmacy or clinic daily for a methadone or sublingual buprenorphine dose.

Naltrexone#

Naltrexone is an opioid antagonist, which means it blocks the opioid receptors in the brain and reduces the effects of opioids completely. It can only be prescribed to prevent relapse for someone who is no longer using opioids.

Characteristics include:

• Before starting naltrexone, a person must not have used opioids in the past 7 to 10 days, or they can experience immediate, acute withdrawal symptoms.
• Naltrexone offers faster detoxification than methadone.
• By itself, it does not cause physical dependence.

Naltrexone may block the effects of heroin, but it may not directly stop a person’s desire to use. It tends to suit people who are committed to no longer using heroin and other opioids. It is a less common treatment option, because remaining abstinent can be difficult for people who have used opioids long-term. Naltrexone works best as part of a comprehensive treatment program that includes counseling.

Advantages of medication treatments#

Some advantages of methadone and buprenorphine maintenance treatments include:

• They are manufactured under strict controls, unlike illicit drugs, which can vary in strength and contain harmful fillers.
• They reduce the risk of overdose.
• They reduce the risk of blood-borne viruses such as hepatitis and HIV and other health risks linked to injecting drug use.
• The effects of heroin last only a few hours, while these treatments can stabilize a person for 24 hours to a couple of days, or longer with long-acting injectable buprenorphine.
• The person no longer has to worry about sourcing the drug, which can reduce anxiety.
• With their dependence stabilized, the person can focus on their health, nutrition, relationships and employment.
• These treatments cost less than heroin, leaving more money for other things.

Starting treatment#

Methadone and buprenorphine treatments are offered through a doctor who is an approved prescriber, or through a specialist drug treatment service. To take part in a program, you generally need to:

• See a doctor who holds a permit to prescribe opioid pharmacotherapy treatment.
• Have regular check-ups, where your doctor will monitor your dose and may test your urine for methadone and other drugs.
• Attend a pharmacy or dispensing clinic for your daily dose, usually paying a dispensing fee. If you are on long-acting buprenorphine, you may only need to attend weekly or monthly.

Remember that it might take a few weeks before the correct dose for you is worked out. Counseling may be optional in some cases, but research shows that people on pharmacotherapy treatment are more likely to succeed if they engage in comprehensive treatment, including counseling. Once a person is stabilized, take-away doses of methadone or buprenorphine may be possible if the doctor considers it appropriate.

Key points#

• When a person becomes dependent on heroin or other opioids (such as morphine or codeine), they may need treatment and support.
• Before starting a treatment program for drug dependence, it is important to understand what is involved.
• A doctor experienced in drug treatment, or a drug counselor, can explain the process.
• Methadone remains active in the body for longer than heroin.
• Treatment allows someone to remain stable while making further positive changes in their lives.

Where to get help#