Heroin dependence - medication treatments

When a person becomes dependent on heroin or other opioids (such as morphine or codeine), they may need treatment and support. Medication treatments (pharmacotherapies) for heroin or other opioid dependence include methadone, buprenorphine and naltrexone.

Before a person 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 counsellor, can explain the process.

An approved prescriber can prescribe a regular dose of methadone or buprenorphine to a person who is heroin dependent.

Methadone as a treatment for heroin dependence

Methadone remains active in the body for longer than heroin. Its effects last about 24 hours, with the peak effects felt 4 to 8 hours after taking the dose. This means only a single daily dose is needed. This allows someone to remain stable while making further positive changes in their lives. Methadone also reduces risky behaviours such as injecting and is much cheaper than acquiring heroin or other illicit opioids.

Methadone treatment can be long-term (months or years), to help the person reduce the risks of using illicit drugs, or short-term (two weeks or less), to help the person safely withdraw from heroin.

Methadone is usually taken as a drink in syrup form, but is also available in injectable and tablet form (more common if prescribed for pain relief).

Effects of methadone

Methadone is an opioid. It does not give a person the same euphoric sensation (‘high’) that heroin does, but it has some similar effects and prevents the person from experiencing withdrawal symptoms.

Effects may include:

• pain relief
• feelings of general wellbeing
• reduced blood pressure
• slower heart rate
• drop in body temperature.

Side effects of methadone

Methadone sometimes leads to unpleasant side effects, but adjusting the dose can help. In some cases, side effects are caused by:

• taking more than the recommended dose
• taking a dose that is too small, leading to withdrawal symptoms
• using other drugs or medications at the same time, such as alcohol or benzodiazepines (tranquillisers).

Mixing methadone with other drugs can have serious side effects, including death. While taking methadone, it’s best to avoid:

• alcohol
• heroin and other opioids
• sedatives, tranquillisers and sleeping pills (benzodiazepines)
• all prescribed pain relievers containing dextropropoxyphene
• dilantin (epilepsy medication)
• any other type of depressant drug, such as GHB.

Side effects of methadone treatment can include:

• Withdrawal symptoms, if your dose is too low. These types of symptoms will begin around days 1 to 3 and peak at day 6. They include difficulty sleeping, aggression, irritability, abdominal cramps, tremors, spasms and drug cravings.
• Lowered blood pressure, dizziness and shallow breathing, if your dose is too high
• Tooth decay – as with heroin and other opioids, methadone dries up the saliva in your mouth, resulting in tooth decay. This can be minimised with good oral hygiene
• Menstrual changes
• Sweating
• Constipation
• Sexual dysfunction (low sex drive)
• Drowsiness
• Heart palpitations
• Dizziness
• Nausea and vomiting
• Skin rashes and itching.

Methadone does not suit everyone. Some people may be more suited to buprenorphine, or other treatment methods such as detoxification and residential rehabilitation.

Methadone for pain relief

Methadone is not only used to treat opioid dependence. Specialist pain doctors sometimes prescribe methadone to treat certain chronic pain conditions. This type of methadone is more commonly prescribed in tablet form.

Buprenorphine as a treatment for heroin dependence

Buprenorphine is a partial opioid agonist. This means it still produces opioid effects but it is not as strong as a full agonist like methadone. It also has a ceiling effect, where its effects are ‘maxed out’ and can’t get any stronger even if more doses are taken. The two main formulations of buprenorphine in Australia are Suboxone (film placed under the tongue) and Subutex (tablet). Suboxone film is a buprenorphine and naloxone formulation, whereas Subutex is buprenorphine only.

Characteristics of buprenorphine include:

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

Long-acting injectable buprenorphine (Buvidal®, Sublocade®) is also available for some patients, with injections given either weekly or monthly depending on individual needs. This new form of buprenorphine helps with some of the challenges people face having to attend a pharmacy or clinic daily to receive their methadone or sublingual buprenorphine dose.

Naltrexone as a treatment for heroin dependence

Naltrexone is an opioid antagonist, which means it blocks the opiate receptors in the brain, reducing 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 treatment, a person must not have used opioids in the past 7 to 10 days, or they can experience immediate and acute withdrawal symptoms.
• Naltrexone offers faster detoxification than methadone.
• By itself, naltrexone does not cause physical dependence.
• Naltrexone may block the effects of heroin, but it may not directly stop a persons desire to use.
• Naltrexone treatment may only suit people who are committed to no longer using heroin and other opioids.
• Naltrexone is a less common treatment option, as remaining abstinent can be difficult for people who have experienced long-term use.
• Naltrexone works best as part of a comprehensive treatment program, which includes counselling.

Advantages of medication for heroin dependence

Some of the advantages of methadone and buprenorphine maintenance treatments include:

• It reduces the risk of blood-borne viruses such as hepatitis and HIV and other health risks associated with injecting drug use
• It reduces the risk of overdose
• They are manufactured using strict controls, unlike illicit drugs, which can vary in strength and contain harmful fillers.
• The effects of heroin last only a few hours, while pharmacotherapy treatments can stabilise a person for 24 hours to a couple of days, or longer in the case of long-acting injectable buprenorphine.
• For someone that was dependant on heroin, they no longer have to worry about sourcing the drug, which can reduce anxiety
• With their dependence stabilised, the person can focus on looking after themselves, including improving their health, nutrition, relationships and employment situation.
• Pharmacotherapy treatments cost less than heroin, so the person has more money to use for other things.

Starting treatment for heroin dependence

Methadone and Suboxone treatments are offered through a doctor who is an approved prescriber or through a specialist drug treatment service.

To be part of a program, you need to:

• See a doctor who holds a government permit to prescribe opioid pharmacotherapy treatment
• Have regular check-ups with your doctor – they will monitor your dose and may test your urine for methadone and other drugs
• Visit your local pharmacist or dispenser for your daily dose (you will need to pay a dispensing fee once a month when attending the pharmacy or dispensing clinic). If you are on long-acting buprenorphine, you will only need to attend weekly or monthly
• Remember that it might take a few weeks before the correct dose for you is worked out
• Visit a counsellor. This may be optional in some cases, but research shows that people on pharmacotherapy treatment are more likely to be successful if they engage in comprehensive treatment, including counselling.

Once stabilised on treatment, there is options for take-away doses of methadone or buprenorphine if it is deemed appropriate by the doctor. Watch Harm Reduction Victoria's videos about the treatment process.

Where to get help

• In an emergency, always call triple zero (000)
• Emergency department of your nearest hospital
• Your GP (doctor)
• Pharmacotherapy Advice Mediation Support (PAMS), Tel. 1800 443 844 – A phone service that assists with pharmacotherapy issues between clients, prescribers and dispensers, as well as providing information on how to find a prescriber or clinic.
• NURSE-ON-CALL Tel. 1300606024 - for expert health information and advice (24 hours, 7 days)
• DirectLine Tel. 1800 888 236 – for confidential AOD counselling, information and referral.
• Youth Drug and Alcohol Advice service (YoDAA), Victoria. Tel. 1800 458 685 (9am to 8pm, Monday to Friday)
• Family Drug Help. Tel. 1300 660 068