Practice Profile: Opiate Maintenance Therapy for Persons for Persons Who Use Heroin and Cocaine

A medication-assisted treatment for opioid dependence, including methadone, buprenorphine, and Levo-Alpha-Acetymethadol (LAAM). The overall goals are to help opioid-addicted patients alleviate withdrawal symptoms, reduce or suppress opiate cravings, and reduce the illicit use of opioids (such as heroin). The practice is rated Effective for achieving higher sustained heroin abstinence for persons who abuse heroin and cocaine abusers, but Ineffective for cocaine abstinence.

Practice Goals

Opiate maintenance therapy (OMT) is a medication-assisted treatment for opioid dependence. OMT works as a pharmacologic intervention for patients in drug treatment and detoxification programs for dependence to opioids, such as heroin. The overall goals of OMT are to help opioid-addicted patients alleviate withdrawal symptoms, reduce or suppress opiate cravings, and bring about a biochemical balance in the body to reduce the illicit use of opioids.

Target Population

OMT is targeted at individuals with opioid dependence problems. Opioids include narcotics such as heroin, morphine, and oxycodone.

Practice Components

Opioids essentially work as sedatives and can cause feelings of euphoria in users. Some forms of opioids, such as morphine, are prescribed to patients as painkillers. Opioids cause a release of excess dopamine in the body, and users can become dependent because they need opiates to continuously occupy the opioid receptor in the brain. OMT works by occupying this receptor and blocking the euphoric high that usually comes from illicit opioid drug use, thereby discouraging abuse and reducing the desire to seek drugs (Mattick et al. 2009).

There are various forms of OMT, such as methadone, buprenorphine, and Levo-Alpha-Acetymethadol (LAAM). Dosage is determined by several factors related to the patient, such as opioid tolerance level, history of opioid use, age, and current medical status.

Additional Information

Some research has found that cocaine use is present in about half of patients receiving OMT for opioid dependence (Castells et al. 2009; Feri, Bruneau, and Stewart 2003). Pharmacologically, opioids and cocaine are very different types of drugs. As stated above, opioids work as sedatives and are commonly prescribed as painkillers. Cocaine acts as a stimulant, causing a sudden rush and high in users. Dual use of the drugs can occur simultaneously (such as injecting heroin and cocaine at the same time (i.e., a “speedball”]), or separately (such as injecting cocaine immediately before or after heroin use). It is not well understood why individuals would use both drugs, which cause such different reactions, at the same time. One study, based on mostly anecdotal information, suggests that possible reasons for dual use include that the combination of both drugs feels different or better than the feeling from heroin or cocaine alone; or that the combination is used for self-medication (Leri, Bruneau, and Stewart 2003).

Although OMT is available to treat opioid dependence, currently there are no federally approved medications to treat cocaine addiction. There is research to suggest that cocaine use has been associated with poorer outcomes of OMT with regard to reducing the illicit use of opioids (Castells et al. 2009). Therefore, it may be important to address cocaine use among opioid-dependent patients receiving OMT, so the effectiveness of the intervention is not diminished.

To explore this issue, the studies included in the meta-analysis by Castells and colleagues (2009)–which was assessed for this review–specifically examined the effectiveness of OMT on heroin abstinence and cocaine abstinence of heroin- dependent individuals with a comorbid cocaine use disorder.

The meta-analysis by Castells and colleagues (2009) included additional tests—called moderator analyses—to see if any factors strengthened the likelihood that opiate maintenance therapy (OMT) improved outcomes for dual heroin–cocaine abusers. When examining studies that compared the efficacy of equivalent doses of methadone and buprenorphine, the results showed that methadone was more effective than buprenorphine in achieving sustained heroin and cocaine abstinence. Methadone was also associated with a decrease in cocaine use and treatment retention. Heroin use was lower with methadone, but not significantly different than buprenorphine. Thus, the results suggest methadone is more efficacious than buprenorphine for dual heroin–cocaine abusers. The moderator analysis also examined the use of psychological interventions in conjunction with OMT for dual abusers. One intervention is contingency management (CM), which is designed to reinforce either cocaine abstinence alone or simultaneous heroin and cocaine abstinence, usually through the use of vouchers, prizes, or opportunities to work for pay. When CM reinforced only cocaine abstinence, there were higher rates of sustained cocaine abstinence, and decreased use of cocaine and heroin, but there was no impact on sustained heroin abstinence. When CM reinforced abstinence from both heroin and cocaine, there was no significant effect on sustained cocaine or heroin abstinence, and only a small effect on cocaine use (there was no effect on heroin use). Finally, when CM was combined with cognitive behavioral therapy, there was a large impact on cocaine abstinence (although no impact on other outcomes). Thus, OMT combined with psychological interventions such as CM, which reinforce cocaine abstinence (rather than both heroin and cocaine abstinence) can improve cocaine use of dual abusers, but CM that reinforces abstinence from both heroin and cocaine does not improve use of both drugs.

These sources were used in the development of the practice profile:

These sources were used in the development of the practice profile:

Leri, Francesco, Julie Bruneau, and Jane Stewart. 2003. “Understanding Polydrug Use: Review of Heroin and Cocaine Co-Use.” Addiction 98:7–22.

Mattick, Richard P., Courtney Breen, Jo Kimber, and Marina Davoli. 2009. “Methadone Maintenance Therapy Versus No Opioid Replacement Therapy for Opioid Dependence (Review).” Cochrane Database of Systematic Reviews, Issue 3.

Following are CrimeSolutions-rated programs that are related to this practice:

Interim Methadone Maintenance (Baltimore, Md.)

Naltrexone for Persons on Federal Probation

New South Wales (Australia) Prison Methadone Maintenance Program

Why might a practice's outcome ratings differ from the ratings of specific programs encompassed by that practice?