Expert: Jacqui - 11/30/2007

Question
QUESTION: My boyfriend has been on the methadone programn for 2 months but he is starting to struggle with the idea of giving up methadone and going back to injecting heroin. He has his daily dose but still finds himself craving heroin and often gets depressed by these feelings. He has a very respectable full time job, so upping his dose isnt the answer as previous attempts at that make him fall asleep at work. Im affraid he is going to go back to using, what else can he/I/we do to help overcome these cravings/fears and get him to continue with methadone? thank you!

ANSWER: Hi Katy. Yes many people don't realise that many heroin users do have respectable jobs and it is often more difficult for people in this situation.  Methadone appears to have the best outcomes when it is used for maintenance therapy (ie: people stay on it for a long time - usually more than a couple of months), rather than as a withdrawal medication (just to get people over the withdrawal effects).  There is probably a little bit more info that I would need - ie: has your boyfriend been on methadone before?  Did it work for him last time?  What is his dose? There are no easy answers, and if I knew how people could stop using drugs I could bottle it and be a millionaire!  Depending how much heroin a person was using, an effective methadone dose can be approx 40 - 80mg.  My first suggestion is to put his dose up, but to arrange for him to take it after work (is that possible in the US? - do you get takeaway doses there?).  That way he is at home and it doesn't matter so much if he gets drowsy.  Generally, the higher the dose, the less people want to use heroin.  If he takes it in the evening, by the time he gets up the next morning to go to work, it should've evened out a bit and not make him so drowsy.  From a non-methadone standpoint, counselling can be helpful - although not always.  Although as he is feeling depressed from his cravings, it may be helpful for him to engage in counselling with a supportive and understanding counsellor.  Often people can be okay when they don't have triggers around them.  I take it you don't use, so trying to spend more time with your partner, and occupy yourselves with other activities.  Sometimes the financial incentives of not using can be huge - so instead of spending a fortune on heroin, your partner could be indulging another pass-time with the money he would've spent.  Finally, if he does use, it is best that you stay supportive of him as long as you feel you can.  If people 'lapse' and then feel isolated by angry responses from others, it can be a slippery downhill slope.  Also, he needs to obviously make sure that he uses as safely as possible so that he doesn't put himself at risk of an overdose or HIV infection.  Many people have little relapses after stopping, but then get over it.  Few people stop once, and stay stopped!  Katy, I am sorry that I can't offer any magic solution to your problem.  If you feel that you need to get assistance for yourself, perhaps you could look at some options for supportive counselling.  Let me know how you go.  Thanks, J

---------- FOLLOW-UP ----------

QUESTION: Thanks Jacqui, we are actually in Australia also!
He hasnt been on methadone before, he ended up using heroin just to cope with each day and is currently on 30mg a day of methadone. He started on 40mg but that was sending him to sleep to the point where he couldnt function at work. No I dont use and thats where I dont understand how he is feeling emotionally and physically...although im a very understanding person I never get frustrated by not knowing.
I keep telling him to give it more time, is that going to help? Is it more a matter of upping his dose? He cant get take-away doses as yet. If they up his dose and he can take it at night is he likely to feel the affects of the methadone late into the next day?
I feel as though he already has it in his head that its all too hard and quitting and going back to using is the easiest option. I dont know how else to help him.

Answer
What a coincidence!  Anyway, the different states in Australia vary quite a bit, however in Victoria yes, he would have to wait about 2 months for takeaway doses.  I do believe that it is worth a try to take the dose at night, although it is not a guarantee that he won't be drowsy.  He may, however, find it harder to get up in the morning, so you might just have to help be his alarm clock!  I believe the peak of his dose is about 3 to 4 hours after he takes it, so if he takes it after work (is he at a pharmacy that opens until late?) then it would probably peak at about 9pm.  His dose is not particularly high (some of the clients I see through work are on 120mg!!!!), but if he hadn't been using for that long, and he wasn't using massive amounts, then he will still feel drowsy from it. This should adapt over time.
The other thing that he might want to look at is counselling.  However, it can sometime be difficult to find options for counselling that are right for the individual.  If he is working then he obviously can't go to some of the services that are open during the day (and he might not want to as some working former users don't' like hanging around an alcohol and drug treatment services because they feel that they are 'stereotyped').  There is now a provision in Medicare for people to have counselling through private psychologists (with a referral from a GP).  It is only 12 sessions max, but he might find this helpful.  He would, however, have to find the right counsellor who has experience in the area.
My final suggestion is that there is another option for pharmacotherapy treatment which is buprenorphine.  This is a tablet that dissolves under the tongue and it tends to make some people much less drowsy than methadone.  It is what's called a partial antagonist so it actually blocks other opiates in higher doses, so if he was to use on top of it, he wouldn't feel it.  It is also a partial agonist, meaning basically that it will provide some kind of opiate like effect.  If you are in Victoria, this medication is combined with naloxone which they put in to stop people injecting it! (and by the way, it hasn't really worked - people who wanna inject stuff will inject it - but that is another discussion - it is incredibly dangerous injecting something that has been in your mouth though - or someone elses mouth!!)   
Let me know how you go!!!!! Jacqui