MOUD stands for Medications for Opioid Use Disorder.

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Though MOUD-type models are now used in a variety of addiction treatments, it got its start treating individuals who were addicted to opioids using Methadone.  Though opioid addiction epidemics are as old as recorded history, MOUD sprang out of the inner-city epidemic in New York City in the 1960s.  Dr. Vincent Dole, a well-respected National Academy of Science internist, became convinced that heroin-addicted persons were suffering from a chemical imbalance in their brain that was best treated by substituting Methadone for the Heroin they were getting illicitly.  He recruited another well-respected physician, Dr. Marie Nyswander, who had written a controversial book published in 1956 entitled the The Drug Addict as a Patient.  Dr. Nyswander shared the same conviction about opioid addiction as Dr. Dole.  They recruited a young woman internist, Dr. Mary Jean Kreek, who became perhaps the best champion of fighting against stigma for MOUD prior to her death in 2021.  Though Drs. Dole and Nyswander passed away many years ago, I had the privilege of meeting and hearing Dr. Kreek speak on many occasions prior to her passing. I am a great admirer of her convictions, clinical/research work, and outspoken advocacy on behalf of those suffering from opioid addictions.

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Their research team at Rockefeller University recruited Heroin addicts with at least 5 years of prison time to participate in a very controlled study using Methadone as a maintenance medication.  The goal was to hopefully prevent the terrible pain of both acute and chronic withdrawal while blocking the effects of Heroin and reducing or removing the urge to use.  The rigors of their studies and outstanding results lead to published papers in highly esteemed medical journals.  

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Dr. Dole’s son, a successful businessman, was a keynote speaker at an AATOD (The American Association for the Treatment of Opioid Dependence) convention some years back. He was a very entertaining speaker, sharing his adolescent memories of that era.  One poignant recollection was of a Nobel Prize laureate at a party asking his father, “Vincent, why are you getting involved in this messy business of Methadone?”.  Dr. Dole, without batting an eyelash responded, “Because they are patients”.

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Their strong convictions and pioneering work in this area led a conservative Republican president, Richard Nixon, to approve the roll out of clinics across America modeled after their MOUD research.  UC Davis staffed and ran the clinics for Sacramento County during my years as a medical student at UC Davis.  As mentioned above, when I became a licensed physician during my psychiatry residency, this was the site of my first paid job.

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What is Methadone

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World War II German researchers discovered the drug,
Seeking pain relief was where they dug.
The long half-life outlasted the relief of pain
But freedom from withdrawal, the addict did gain.

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The Germans discovered Methadone during World War II as they looked to better manage painful war-related injuries.  Heroin has a very short half-life, quickly enters the brain, and is active as Morphine on the brain Mu receptors.  Methadone, on the other hand, has a relatively long half-life, generally in the range of 24 to 48 hours, attached to these same receptors.  Once a person becomes physically addicted to Heroin, the very unpleasant withdrawal symptoms start as it is broken down and the receptors in the brain that alleviate pain and create a feel-good (or ‘being high’) sensation no longer have it around.  Methadone, with its long half-life, can be taken once daily, eliminating withdrawal symptoms.  What Dr. Dole and his team further discovered is that properly dosed, addicts did not experience a high or loaded feeling.  If, in this properly dosed range, they tried to use Heroin, the high they previously experienced was blocked.  Money spent to get high was essentially wasted!  The anxiety related to securing their next fix and fear of arrest was effectively reduced and/or eliminated.

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Subsequent experience with Methadone has demonstrated that it is very effective in alleviating pain but usually only for about 8 to 12 hours.  This means that a Heroin-addicted person who does not have an underlying pain issue needs only to take their daily dose once.  A heroin addict who has an underlying pain condition can divide their dose in half or thirds to get the benefit of the 8 to 12 hours of pain reduction following each dose.

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