Eyes Wide Shut? – A Conceptual and Empirical Critique of Methadone Maintenance Treatment

Abstract

Background: Methadone maintenance treatment (MMT) has been the ‘gold standard’ pharmacotherapy treatment for illicit opioid dependence for over 30 years. It has been widely evaluated, and is generally claimed to be ‘effective’. Methods: The objective of this paper is to review the rationale of MMT as an intervention for a biomedical disorder with primary social objectives as well as the methodological quality and evidence of MMT outcome research. Data sources included opioid dependence treatment practice, review and outcome research literature (1965–2001) in the form of peer-reviewed articles, books, monographs and reports that are preeminently cited and reviewed international studies on MMT. Results/Data Synthesis: Rigorous and appropriate evaluation (i.e., RCTs, intent-to-treat, patient-centered) methods in MMT evaluations are rare. Evidence of MMT’s effectiveness on primary treatment objectives is mixed and appears to be largely partial and short-term. Positive outcomes may be the result of selection effects of compliant patients and loss in proportion when more rigorous standards of analysis are applied. Conclusions: The quality of existing MMT research, and evidence for its general effectiveness are limited. Key concepts of self-medication and psychiatric comorbidity are largely ignored in MMT treatment and research frameworks, although they may serve to explain MMT’s limited treatment success. Emerging new opioid pharmacotherapies require the fundamental review of the existing MMT paradigm as well as the application of rigorous and appropriate evaluation methods for future treatment.

Neuropsychological functioning in opiate-dependent subjects receiving and following methadone maintenance treatment

“…We did not control for cigarette use in our subject groups. Finally, we chose to perform a cross-sectional study on two sample groups rather than a longitudinal study of MMT patients pre-and post-detoxification because not all of the MMT patients will successfully continue in drug treatment, and of those that do; only a portion will elect methadone detoxification (Cushman, 1977;Fischer et al, 2005). This means however, that a self-selection bias is introduced into the PA group.…”

Treatment satisfaction and quality of support in outpatient substitution treatment: opiate users’ experiences and perspectives

“…Until today, most evaluation studies of opiate substitution treatment have focused on objective, socially desirable outcomes such as the reduction of illicit drug use, health risks associated with drug use and criminal behavior, with limited attention for outcomes important to opiate-dependent individuals themselves (Barnett & Hui, 2000;De Maeyer, Vanderplasschen, & Broekaert, 2009;Fischer, Rehm, Kim, & Kirst, 2005;Ruefli & Rogers, 2004). Drug users are seldom seen as important sources of information and their personal perspectives about substance abuse treatment and life in general are not widely reported in the literature (Drumm et al, 2003;Fischer, Rehm, & Kim, 2001;Kolind, 2007;Montagne, 2002), even though such studies may present an alternative perspective on these issues (Brun & Rapp, 2001;Vanderplasschen & De Maeyer, 2007).…”

Exploratory Study on Drug Users’ Perspectives on Quality of Life: More than Health-Related Quality of Life?

“…quality of life, satisfaction with treatment) have largely been neglected (Fischer et al 2001a, b). This reflects the utilitarian perspective on substance abuse treatment outcome research that has predominated during the last 25 years, concentrating on public nuisance, social and economic costs, costeffectiveness and societal benefits (Barnett and Hui 2000;Fischer et al 2005). Few studies have focused on the question whether these outcomes are congruent with the perspectives of drug users themselves (Fischer et al 2001a, b).…”