WASHINGTON (AP, Nov 1, 1995) -- Methadone should be used to treat people who have been addicted to heroin or similar drugs for over a year, even though the controversial medication is itself addictive, psychiatrists say.

The advice is among the American Psychiatric Association's new guidelines for treating substance abuse. Published Wednesday in the Journal of Psychiatry, the recommendations are the nation's first list for doctors of which therapies are proven to work and which aren't.

``There has been a fair amount of uncertainty as to what constitutes appropriate treatment,'' said Dr. Steven Mirin of McLean Hospital in Belmont, Mass., who led the guidelines' development. ``These guidelines are an initial effort to place treatment on a firm scientific footing.''

Take methadone, the controversial medicine that weakly imitates opiate drugs like heroin and is used to help addicts wean themselves. But because it, too, is addictive, its use is restricted to special government-controlled clinics that have long waiting lists. Methadone is the only medicine so limited, and some states have even banned it.

The Institute of Medicine last year recommended the government loosen methadone restrictions, and the APA guidelines now say that methadone in addition to conventional psychotherapy offers opiate addicts the best hope.

``Methadone needs to be seen not as a distasteful alternative but a front-line treatment,'' Mirin said. Some addicts may need methadone for life, much as diabetics take insulin, he added.

An estimated 5.5 million Americans need treatment for drug abuse and 13 million others are alcoholics, according to the Institute of Medicine. Substance abuse costs some $300 billion a year in direct medical expenses, crime and lost productivity.

But how to treat these people is hotly debated, prompting the APA to draft the guidelines. They are intended not just for psychiatrists but other health care workers who treat substance abusers and for insurers to use in deciding what therapies to cover.

The main message: A single treatment hardly ever works. Patients must be weaned from drugs, manage withdrawal, manage stress and other social conditions that drive them to drugs, and be treated for underlying diseases that fuel the addiction or were caused by it, the guidelines say.

Among the recommendations:

-- Most cocaine addicts needs intensive outpatient treatment, meaning sessions more than twice a week. There is no medication that helps. The National Institutes of Health this week designated five Veterans Affairs medical centers to test new medications to battle cocaine addiction.

-- The medicine naltrexone can help wean people from opiates by blocking the drugs' effects, but only the most motivated patients use it. Alcoholics may also benefit from naltrexone or the medicine disulfiram, which discourages drinking by causing unpleasant side effects when it meets alcohol in the body.

-- Cognitive therapy that teaches patients to recognize and avoid the behaviors that encourage their addiction, such as stress, and to manage cravings is the most effective psychotherapy.

-- Patients should be treated in the least restrictive setting, but those at risk of severe withdrawal are candidates for hospitalization. Addicts who lack social and vocational skills or who live in drug-infested surroundings should enter residential treatment programs for at least three months.

-- Self-help groups like Alcoholics Anonymous can be vital, but people who feel uncomfortable in these groups should not be labeled treatment failures.