Table of Contents
An opioid is a type of drug that relieves pain by blocking pain signals to the brain. Opioids come in many forms, including pills, patches, powders, and liquids. Also called opiates or narcotics, opioids come in various strengths -- from very strong (e.g., morphine, Dilaudid, Duragesic, Oxycontin), to moderately strong (e.g., oxycodone, as in Lortab, Percocet), to strong (e.g., hydrocodone, as in Vicodin) to mild (e.g., codeine, as found in some cough/cold medicines). Heroin is made from morphine and can be injected, snorted, or smoked.
Opioids block the body's perception of pain. For some people, opioids also cause an intensely rewarding 'rush' or sense of extreme happiness. Although opioids can be effective and safe when taken as prescribed, they can also be highly addictive. This means that those who take or use opioids can lose control, become dependent on them, and use more and more of them. For more information, see The Well Project's article on Substance Abuse and Addiction.
People who inject drugs, whether they inject heroin or another illegal substance, are more likely to get HIV, hepatitis C and/or B, and other infectious diseases through sharing or reusing needles and other injection drug equipment. It has been estimated that close to one in ten new HIV infections worldwide are the result of injection drug use. In some parts of Central Asia and Eastern Europe, unsafe injection practices are the cause of more than eight out of ten HIV infections. Of the three to four million people newly infected with hepatitis C each year, around two million of these are due to injection drug use. For more information on safer injection practices, see The Well Project's article on Cleaning Works.
Opioid Substitution Therapy (OST)
Opioid substitution therapy, also called opioid replacement therapy or maintenance therapy, provides opioid addicts with a prescription medicine that replaces their drug of choice (e.g., heroin) and helps them manage their addiction. This medicine is usually supplied in a clinically supervised setting. The two medicines most often used as OST are methadone and buprenorphine; they are described below.
According to the World Health Organization (WHO), studies have shown that OST programs are effective in reducing illegal drug use, death from overdose, and behaviors that lead people to get and spread HIV. They also help those living with HIV (HIV+) to adhere to their HIV drugs and stay healthier longer. Unfortunately, less than eight percent of people who inject drugs worldwide receive OST. However, this number varies greatly depending on the country. While as many as nine out of ten injection drug users get OST in the United Kingdom, OST is unavailable in the Russian Federation. In the US, it is estimated that around one in four opiate addicts receive OST.
What Are Methadone and Buprenorphine?
If you are addicted to heroin or another opiate, your health care provider may recommend treatment with methadone or buprenorphine. They are both prescription drugs that can help you manage your addiction. It is important to know that both methadone and buprenorphine are addictive. That is, your body becomes dependent on your taking them and could have withdrawal symptoms if you stopped (e.g., anxiety, sweating, chills, rapid heart rate, nausea, vomiting, diarrhea). However, they take away your craving for heroin and do not make you feel high or tired. Methadone does not interfere with day-to-day activities such as driving a car or going to work, but buprenorphine may cause drowsiness.
Each dose of methadone lasts for about 24 hours so you will only need to take it once a day. Used at the appropriate dose, methadone is a safe drug that may not have difficult side effects even if you take it for ten years or more. Like any drug, it is possible to take too much methadone or buprenorphine and overdose. Symptoms of overdose for methadone and buprenorphine include slow breathing and heart rates, severe drowsiness, muscle weakness, pinpoint pupils, and cold, clammy skin.
Buprenorphine can be used once a day or once every other day, and is available as a sublingual tablet (dissolves under the tongue). Buprenorphine is less likely than methadone to cause overdose and withdrawal symptoms.
There are several brand-name products containing buprenorphine that the US Food and Drug (FDA) has approved for treatment of opioid dependence: Subutex (buprenorphine), and Suboxone and Zubsolv (buprenorphine + naloxone). Health Canada has approved Subutex and Suboxone, while the government in the UK has approved Subutex, Suboxone, and Prefibin (buprenorphine). The World Health Organization's (WHO) guidelines recommend that health care providers offer substitution therapy for opioid dependence. However, not each country follows these guidelines, and even among those who do, each countryâ€™s preferred method for meeting the WHO guidelines differs.
Combined with behavioral therapies, counseling, and other supportive services, methadone or buprenorphine treatment can help you stop using heroin and other opiates, including prescription narcotics like Lortab, Vicodin, OxyContin, and Percocet. Taking care of a substance abuse problem can greatly increase the success of your HIV treatment.
Can Anyone Get Methadone or Buprenorphine Treatment?
Although the WHO's guidelines for managing opioid dependence suggest that methadone replacement treatment is very effective, access to OST remains challenging in many areas. Methadone and buprenorphine treatment are recognized and available in some countries, yet remain unavailable and illegal in others.
In the US, because methadone and buprenorphine are federally controlled drugs, you must meet the requirements of the FDA. Federal requirements along with state laws can influence whether or not methadone and buprenorphine treatment are available in your area.
You cannot get methadone or buprenorphine in every pharmacy and you may have to go to the clinic to get your medicine. Currently advocates are pushing for methadone and buprenorphine to be treated like any other prescription medications.
What Side Effects Are Associated With Methadone and Buprenorphine?
Methadone's common side effects are constipation and excessive sweating. However, some people on methadone also report having dry mouth, trouble urinating, erectile dysfunction, skin rash, low blood pressure (which can result in feeling tired or dizzy), and nausea. Buprenorphine's side effects include nausea, vomiting, drowsiness, and constipation, and may be less intense than methadone's side effects.
There are street stories that methadone rots the bones and makes teeth fall out. However, there is no scientific or medical evidence that supports these myths.
Do HIV Drugs Interact With Methadone or Buprenorphine?
Methadone and buprenorphine can interact with other medications. Sometimes drug interactions are minor and do not cause any problems. Other times the wrong combination of drugs can cause serious side effects. In addition, any type of liver disease (e.g., hepatitis) may make these interactions worse.
If you are taking opioid treatment and HIV drugs it is important that you be carefully monitored by your health care provider. In some cases methadone and buprenorphine cause the HIV drugs to become less effective. In some cases the HIV drugs cause the opioid treatment medicines to become less effective. It is important to talk to your provider to see if you need to have the dose of your methadone, buprenorphine, or any of your other medications changed.
Some other drugs used by people living with HIV, such as the antibiotic rifampin, which is used to treat tuberculosis, also interact with methadone. Talk to your HIV provider or opioid treatment program associate so they can provide you with the proper medical advice.
If you cannot take methadone because of drug interactions, other anti-opioid treatments may be used:
- Drug therapies such as LAAM (Levo-Alpha Acetyl Methadol), naloxone, and naltrexone
- Detoxification (clearing the body of drugs)
- Behavioral therapies
OST and Pregnancy
Methadone treatment may cause changes to and even stop your monthly menstrual period. It will not, however, prevent you from getting pregnant or from having a normal pregnancy.
Methadone does cross the placenta (the blood supply to the baby) and your baby may be dependent on methadone at first and need to be weaned. Long-term studies have shown that there is no increased risk of birth defects or developmental difficulties in babies born to methadone-treated women.
Buprenorphine has not been as well studied in pregnancy as methadone. Recent studies have shown that buprenorphine treatment can be easier on the baby without an increased risk of birth defects. Recent studies have also shown that the safety and effectiveness of buprenorphine -- for mother, fetus, and newborn -- are very similar to that of methadone. While in the past, methadone was the preferred opioid substitution treatment in the US for women who were pregnant or planning to become pregnant, buprenorphine is now being offered as a treatment to pregnant women who are new to OST. The US guidelines now recommend that decisions about taking methadone or buprenorphine while pregnant should factor in the specific needs and goals of the patient (Federal Guidelines for Opioid Treatment Programs, March 2015).
If you are on methadone or buprenorphine and become pregnant, it is important that you not stop your treatment without first speaking to your health care provider.
Overdose Prevention With Naloxone
Naloxone, also known as Narcan, is a drug that is used to prevent overdoses with opioids. It works by counteracting the effects of opioids. Naloxone can be injected into the muscle, vein, or under the skin. It can also be given via a nasal spray. Naloxone is not addictive and has no potential for abuse. Someone who is experiencing an opioid overdose will usually respond to naloxone within five minutes.
Traditionally, naloxone has been used by emergency medical personnel in cases of life-threatening opioid overdose, which is characterized by a severely slowed respiratory rate, pinpoint pupils, and lack of consciousness. However, bystanders can also use it effectively. Several countries have begun to provide naloxone to those at risk of opioid overdose or to those likely to witness one (e.g., friends and family members of those using opioids). In the US, the American Medical Association supports increased access to naloxone and has a list of states with naloxone and 'good Samaritan' laws here.
Taking Care of Yourself
Opioid substitution therapy is an important tool for treating addiction to heroin and other opiates, including prescription painkillers. Get the most out of your replacement therapy and your HIV drugs by keeping your health care provider informed of all the drugs you are taking, so any necessary dose adjustments can be made.