Recently I was assigned to be on-call at a Methadone Replacement Therapy clinic in our hospital. A shift started at 7 in the morning to 11am on Sunday. Then I went for an hour brunch break before continuing with a shift from 12pm to 5pm at our 24hours pharmacy. I’m not gonna talk about my on-call shift, instead regarding this Methadone program.
Fyi, the Methadone Replacement Therapy (MRT) clinic operates DAILY to cater the needs of our patients through a concept called Directly Observed Therapy well known as DOT, where each methadone syrup dose is taken under a close supervision of healthcare providers. Why is this necessary? Because methadone is an opioid with a high potential for misuse.
My role is basically to double-check each patient’s dose and dispense their methadone syrup accordingly. It's a pretty straightforward task. Probably the easiest pharmacist role in the entire hospital I supposed. However, since methadone is classified as a Dangerous Drug, everything must comply with the Dangerous Drugs Act 1952. That means a lot of documentation is required. So even a 4 hour shift ends up being quite packed.
Documentation has always been a crucial part of any process. Without proper and accurate records, things could easily go wrong. From a patient care point of view, the exact time of methadone administration is important. It influences our decision making, especially when to determine whether or not to give another dose if a patient vomits after taking their daily dose.
I guess you might have some idea who our patients are. Or should I address them as a client? But I’m always comfortable using patients instead. If your answer is drug addicts, yep! you got it right man. My clients are drug addicts. But one common misconception people may perceive is that all drug addicts are entitled to this program. However, that is not the case. Only those drug addicts who are involved with heroin or morphine misused are eligible, while other substances like cannabis, cocaine and methamphetamine aren’t. I’ll explain this later.
Misuse of OPIOIDS has been a serious issue for decades, especially for heroin. It started small, then snowballed. This problem isn’t a one man problem but instead it gives a huge impact not only to a family institution, a society and eventually to our nation of course. Not to mention how the addiction towards heroin leads a person committing an insane-next-level-ridiculously-harm-and-crime to society, especially to their own blood line. That was tragic!
For those who are wondering what an opioid is…
Well, OPIOID is actually a group of drugs that act specifically on the OPIOID RECEPTOR which is adversely found in our central and peripheral nervous systems. When an opioid is binding to its receptor, it will block a pain pathway (nociceptive pathway) therefore preventing a person suffering from pain sensation. However, resulting from that binding it gives euphoric (feeling high) as well as sedative effects.
Opioid is then further classified into 3 main classes namely:
1) Natural opioid: MORPHINE & codeine
2) Semi-synthetic opioid: HEROIN, oxycodone, hydrocodone
3) Synthetic opioid: METHADONE, tramadol, fentanyl
Unlike other types of opioid, HEROIN is well known as a recreational drug and we have never used it for treatment purposes, name it as pain control neither for sedation. You’ll see why.
So why has heroin never been used as a treatment option?
The rapid onset of action heroin is highly linked to its high potential for addiction. A way higher than other opioids mentioned above. Besides, this semi-synthetic drug is able to cross our blood brain barrier extremely quick causing an intense euphoric effect to its user. Not to mention its safety profile is not much better than other choices on the list.
Before we advance further, it is always interesting to know the history right…
Opioids have long been discovered during ancient times by which latex of a Poppy plant (also known as joy plant) is used for pain reliever, sleep induction (sedation) and cough reliever. Later on, in 1804 a German pharmacist isolated morphine from this same plant and then morphine was widely used as a painkiller. However they noted addiction became common among soldiers that were administered with this drug during war.
Heroin on the other hand was first synthesized from morphine in 1874 by a British chemist. It was then marketed widely as a ‘non-addictive morphine alternative’, which was totally wrong. Not long after it was banned from the market by most countries in view of its widespread addiction.
It wasn’t until 1900 scientists managed to synthesize fully synthetic opioids which are much safer and less addictive as we have in the market now as methadone, tramadol and fentanyl. These drugs are widely used in healthcare settings across our country but always with cautions following strict dose and regimen guidelines. Tramadol in particular, is very commonly prescribed by physicians to the outpatients, and its stock flows out of the pharmacy like water!
Back to our main focus, why methadone is chosen over other opioids like morphine, which is also available in our healthcare facility?
As you guys are well-versed now, methadone is a synthetic opioid. It is a man-made drug that is chemically manufactured to act like a natural opioid and does not come from opium poppy. Thus, its chemical structure has been modified to fit the needs. Unlike morphine, methadone is a long-acting opioid, meaning it can stay in the human system for up to 36hours, no kidding. Heroin and morphine on the other hand, last only about 3–6 hours each before they are slowly cleared from our system.
Because of this, dosing frequency is more convenient for patients who usually commit to a single daily dose and a daily visit to the clinic. This also works well from our perspective. Besides, as I mentioned, this man-made drug has a better safety profile and less addictive compared to naturally occurring morphine. Methadone also comes in the form of a syrup, which is easily taken by all generations and age groups, at a strength of 5 mg/ml.
Answering the previous question: why aren’t cannabis, cocaine, and methamphetamine users eligible to be enrolled in this MRT program?
If you understand the concept from the beginning, you might already grasp the answer. It’s simply because these 3 substances do not belong to the opioid group. Therefore, their mechanisms of action are different. They bind to different receptors. For example, cannabis binds to cannabinoid receptors, while cocaine blocks the reuptake of dopamine, which increases dopamine levels in the brain and produces a euphoric effect similar to opioids.
In my personal point of view, Methadone Replacement Therapy introduced by our government is a good initiative in helping heroin and morphine abuser to curb with their cravings and therefore helps them live and function well, better than feeling like a zombie. Think of it as a stepping stone. Something that helps people slowly and safely get their lives back. But obviously it is not a cure for addiction rather a harm reduction strategy. Once a person gets involved in the misuse of these substances, it often feels like there is no way back.
What truly frustrates me, however, is how the corrupt system allows these illicit drugs to remain so widely available in our community. Despite all the efforts and programs, the ease of getting them and the constant supply flooding the market is disheartening. And I strongly believe that this can never be resolved because among the abuser are the enforcers, the VVIPs and the policymakers.
Isn't that right?
How harmful are these psychoactive substances?
Just watch a Netflix series called Narcos, a real-life story of Colombian drug lord Pablo Escobar and the rise of the Medellin Cartel. He's notorious kingpin and the cocaine trade he led had a devastating impact on Colombia and worldwide. The story is well portrayed in the 30 episodes play and definitely worth watching!
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