Is Methadone a good choice for opioid dependence treatment?

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Before we answer this question, let’s highlight several important, antecedent decisions:

Decision #1:  Medication-assisted treatment (MAT) vs. Abstinence treatment?

This should be a personal choice made in collaboration with your support team/network. If you have a record of multiple failed attempts at abstinence therapy or relapses then maybe you should now consider medication-assisted treatment as a bridge to eventual abstinence. 

Decision #2:  Choice of treatment drug: Opioid Agonist vs. Antagonist therapy vs. Withdrawal (“detox”) treatment/symptom management.

If you’ve decided to use medications in your recovery therapy then there are three categories of medications to choose from, depending on the type of MAT that you prefer. These categories are:   

1) Opioid agonist medications

2) Opioid antagonist medications

3) Symptomatic treatment medications

Approved Opioid agonist medications include only Buprenorphine (mono-product or combined with naloxone) and Methadone.

Approved Opioid antagonist medications include Naltrexone.

Symptomatic medications are palliative medications, primarily used to treat opioid withdrawal symptoms. For most, this is an unapproved use. This list frequently includes Clonidine, Lofexidine, and many others not specific to this purpose only, such as sleep meds, anti-nausea meds, etc.

Why Methadone? / What makes methadone a good choice?

  • A long duration of action, allowing convenient once-daily dosing. 
  • There is no dose maximum (but it may have cardiac effects that could limit dose).
  • It can be titrated (dose adjusted) individually to your satisfaction/optimal effect.
  • Methadone is a complete opioid, not a partial one, like buprenorphine.
  • These qualities may allow it to have a more satisfactory/complete effect on the user.
  • Methadone treatment is predictably phased: induction + stabilization >> maintenance >> MSW (medically-supervised withdrawal/tapering off).
  • The duration of therapy is variable/customizable. It can be predetermined or indeterminate. Detox only, short-term vs long-term vs indefinite/open-ended treatment duration.
  • Clinic setting: provides close supervision/monitoring, provides in-house counseling.
  • Slow, gradual detox (medically-supervised tapering off of the medication).
  • Treatment is flexible and adapts to special situations: 
    • Pregnancy
    • Incarceration ( in some jurisdictions)
    • travel/ relocation

My Opinion:

Methadone maintenance treatment is a good choice for medication-assisted treatment. The two biggest hurdles to overcome are mental – the lingering stigma/stereotyping surrounding methadone treatment and secondly, the clinic atmosphere may not be to some’s liking.

The effectiveness of the treatment, however, in terms of saving and rehabilitating lives is undisputed. 

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UNDERSTANDING OPIOID DEPENDENCE*

*Adapted from information provided by Reckitt-Benckiser, manufacturer of SUBOXONE® (buprenorphine HCl/naloxone HCl dihydrate) sublingual tablet

Opioid dependence is a disease in which there are biological or physical, psychological, and social changes. Some of the physical changes include the need for increasing amounts of an opioid to produce the same effect, symptoms of withdrawal, feelings of craving, and changes in sleep patterns. Psychological components of opioid dependence include a reliance on heroin or other drugs to help you cope with everyday problems or the inability to feel good or celebrate without using heroin or opioids. The social components of opioid dependence include less frequent contact with important people in your life, and an inability to participate in important events due to drug use. In extreme cases, there may even be criminal and legal implications 

The hallmarks of opioid dependence are the continued use of drugs despite their negative affect, the need for increasing amounts of opioids to have the same effect and the development of withdrawal symptoms upon cessation.

There are a variety of factors that can contribute to the continued use of opioids. Among these are the use of heroin to escape from or cope with problems, the need to use increasing amounts of heroin to achieve the same effect, and the need for a “high.”

Treatment

Treatment for opioid dependence is best considered a long-term process.

Recovery from opioid dependence is not an easy or painless process, as it involves changes in drug use and lifestyle, such as adopting new coping skills. Recovery can involve hard work, commitment, discipline, and a willingness to examine the effects of opioid dependence on your life. At first, it isn’t unusual to feel impatient, angry, or frustrated.

The changes you need to make will depend on how opioid dependence has specifically affected your life. The following are some of the common areas of change to think about when developing your specific recovery plan:

Physical – good nutrition, exercise, sleep, and relaxation.

Emotional – learning to cope with feelings, problems, stresses and negative thinking without relying on opioids.

Social – developing relationships with sober people, learning to resist pressures from others to use or misuse substances, and developing healthy social and leisure interests to occupy your time and give you a sense of satisfaction and pleasure.

Family – examining the impact opioid dependence has had on your family, encouraging them to get involved in your treatment, mending relationships with family members, and working hard to have mutually satisfying relationships with family members.

Spiritual – learning to listen to your inner voice for support and strength, and using that voice to guide you in developing a renewed sense of purpose and meaning.

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Prescribed, 300 mg of Methadone/day!

Methadone: date synthesized 1937 1950-used in treating opioid withdrawal in US 1964-Used in Opioid maintenance therapy

Yep, I’ve seen it!

It brings up several questions:

Why?

In this case, it was being given in the context of chronic pain management.

Chronic opioid therapy (the therapeutic use of opioid medications over a long period of time) is usually prescribed in the context of adult chronic pain management or medication-assisted treatment of opioid use disorders/addiction.

Why so much?

Undoubtedly, this is a very high dose of this opioid medication.

Methadone is approved/prescribed as an analgesic (pain killer) for severe pain or to treat opioid use disorder/addiction.

Initial doses typically begin at 5 or 10 mg, for analgesia in opioid-naive patients, and up to 40 mg in opioid-tolerant patients.

Patients/clients aren’t routinely started at such high dosage levels. Over time, however, depending on the goals of therapy, such doses may be gradually attained, generally by the process of slow titration (accumulation) of the medication, as the person’s tolerance for the opioid medication also rises.

This is what keeps the process safe.

 Still, there may be some question as to why such a high dose is required to attain the therapeutic goal.


Is it dangerous?

Yes, potentially. Opioid medications have many side effects and dangers if misused. Both the prescriber and the person taking the drug should be aware of this and appropriate precautions are taken to minimize complications. All medicines have side/undesirable effects, and some are unavoidable.

 One crucial caveat when taking opioid medications is to not combine their use with other sedating medications or products.

Clients/patients prescribed/taking opioid medications should be monitored closely for adverse reactions/situations. These should be discussed before embarking on this therapy, and patients/clients should be appropriately screened before prescribing opioid medications. 

Is it appropriate?

Opioid medication use and chronic opioid therapy are appropriate for the correct indications and under the right circumstances.

The medical community is still learning how to prescribe opioids safely, especially chronically. Before prescribing, prescribers should appropriately screen their patients, no different than for any other medication, alerting them to the unique dangers inherent to opioid drugs. After prescribing, frequent, ongoing monitoring of medication use, effectiveness, etc is necessary.#methadone #opioids #opioid treatment

In the Clinic today…(2)

A series presenting real encounters in a Methadone Maintenance Treatment (MMT) program. Hopefully revealing how this common medication-assisted approach to opioid addiction treatment might work for you:

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The scenario:

An established client comes in for his annual medical review (each program has a physician medical director who assesses each client on entry to the program, annually and as needed). He’s doing well and is on a stable dose of 140 mg/day of Methadone with take-home privileges (that means that this client doesn’t have to come to clinic daily for methadone dosing. He has earned the privilege of receiving several individually packaged “take home” daily doses, which he self-administers). This client feels well and has no complaints. He has a chronic pain issue and wants to remain on methadone indefinitely or at least for the foreseeable future. He is overweight and smokes tobacco products.

The Issues:

For him, there are no major issues and that is good. He feels satisfied with his progress so far in treatment and his recovery using Methadone. We discussed several considerations for further enhancing his recovery from opioid use disorder (OUD)/addiction, while in medication-assisted therapy (MAT) with methadone (MMT). Some of these issues were:

  • Smoking Cessation: Many clients in substance use disorder recovery smoke and traditionally this has been overlooked, as the lesser of two evils. More recently however more emphasis is being put on smoking cessation, even while in therapy for illicit drug use/addiction because of the devastating long term health consequences of tobacco/nicotine addiction.

  • Weight management/Diet & Nutrition: Many clients gain weight in therapy as their lifestyles become less disordered. At this time it becomes essential to focus on diet and nutritional issues. This is a frequent complaint and occurrence in MMT and often methadone is blamed. Regardless of the cause, I encourage clients to become more mindful of the issue and to institute a personal plan to address it.

  • Community level Recovery support: I recommend to all clients to become engaged in a local, community-level, support group, for people living with/managing chronic illnesses. A good, peer-led, example of this are 12-step programs of recovery, which are based on the AA (Alcoholics Anonymous) model. NA (Narcotics Anonymous), would be the most widely known one specifically focused on opioid use disorder (OUD)/addiction or opioid-dependence. Such programs are usually free and provide opportunites for learning, fellowship, improvements in personal recovery and mentorship, as mentor or mentee.

  • Medically supervised withdrawal/detox from Methadone: This is a jargoned way of saying, “getting off the drug”, or “detoxing”; in this case, the treatment drug is methadone. For methadone, as with/when “detoxing” from any opiate, the process should be slow and gradual, in order not to trigger relapses. This is the final stage in/of any medication-assisted opioid addiction treatment-the reversal of the medically maintained opioid-dependence and the return to total abstinence from all opioids. This is a critical process that should not be rushed and should probably not be attempted solo, unaided/unsupervised.

Summary:

By and large, I’m of the opinion that methadone works well for medication-assistance therapy (MAT) of OUD. There are other MAT medications available, such as Buprenorphine, Naltrexone, and several symptom-targeting medications for relieving short term detox/withdrawal symptoms. Any one of these medication-assistance approaches may work well for individuals but it is virtually impossible to determine, with certainty, which medication choice or technique will work best for any individual. A thorough discussion with an experienced and knowledgeable health/medical provider could go a long way towards revealing biological, psychological, social and historical factors which may point to which treatment option might be more favorable. A fact-finding call or visit to a local Opioid Treatment Program is an easy and cost-free way to accomplish. The cost of treatment is reasonable, especially compared to ongoing active illicit drug use and considering that you’ll be receiving treatment medication and professional counseling at the same location.

Bye for now,

(Dr.) Stu

In the Clinic today…


Here’s the scenario:

Today, in the clinic I had an interesting interview with a client who is in medication-assisted treatment (using methadone) for opioid use disorder (OUD)/addiction. The core of the matter centered on whether it was OK for the client, who is also a chronic back pain sufferer, to be on a legitimately prescribed opioid medication, open-endedly (?) – no firm discontinuation plan, after a failed interventional procedure which caused a flare up in his pain. He states that he’s handling it well and that his appropriate use (as directed by his prescription – 3x daily) is being monitored by his Pain physician and the Clinic counselor. He doesn’t see an issue here…

What’s your opinion, is there an issue of concern here ??

My thoughts:

For me, this is a complex issue, as numerous questions and complexities arise in the context of chronic pain management utilizing opiates, in opioid addicted populations. Some of these issues are:

It depends! (on several factors, two of which I highlight below)

Location:

What might be acceptable for limited durations in certain settings, such as an in-patient facility, for example, might be less so or not at all acceptable, in others, such as in a less strictly monitored outpatient setting. 

Duration of use:

While short term use of opioids for acute pain conditions/flare-ups, even in the setting of OUD, such as perioperatively, trauma, etc is widely accepted. Is chronic opioid therapy for pain management ever acceptable for/in an opioid use disorder patient who is in recovery and abstinent or on opioid-agonist medication – assisted treatment ?

How I resolved the matter:

I asked the client to discuss the matter with his pain management physician and together implement a plan to be off the opioid pain medication within 90 days. I consider it a “judgement call” on my part and think it was a “safe decision” but certainly not the only possible decision.

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Tell me what you think. Send comments to continue the conversation or begin new ones.
Stu.

Improvements to come…

I’m new at publishing publicly so these early posts may be hard to read visually. I’m learning about how to make them more appealing visually and easier to read. I’m also considering how to proceed in terms of relevancy and that’s where I need feedback from you in terms of what you’d like to receive commentary/posts on in this arena.

In the meantime I’ll try to address posts to what I’d consider my ideal audience and I’m considering a series consisting of FAQ responses to questions I’ve come across from clinic clients over the years. I think that would be interesting to many who are curious about Opiate addiction treatment using methadone.

Sincerely,

Stu

My First Blog Post

Please come back!

Good content to follow…

Be yourself; Everyone else is already taken.

— Oscar Wilde.

This is the first post on my new blog. I’m just getting this new blog going, so stay tuned for more. Subscribe below to get notified when I post new updates.

Introduction

Hi, my name’s Stuart and I’m a physician who’s been involved with medication-assisted opioid addiction treatment (MAT) since 2006 and Methadone maintenance therapy (MMT)since 2008. I was formally trained in Anesthesiology and Pain management. Currently I’m a co-medical director at a small Opioid Treatment Program (“Methadone clinic”) in a small city in the U.S.A. These are my experiences, perspectives and observations from several years of working in this field.

Why do this?

  • This activity provides a platform to talk about/publicize the benefits of MAT & MMT
  • To “pull back the curtain”, explain & describe how and why MAT & MMT works
  • Appeal to curious, prospective clients, families and clinicians

What topics will I write about?

  • Anything pertaining to medication-assisted treatment of Opioid use disorder (OUD)
  • Methadone & methadone maintenance therapy
  • Life as a clinic client (patient)
  • Issues surrounding Substance use disorders/addiction and Recovery
  • Any other related topics or issues that readers would like discussed

Methadone Maintenance Therapy- an Introduction:

This is my first attempt at public writing so please accept my apologies in advance. My wish is to impart some of my knowledge, observations and opinions garnered from years of working as Medical Director in small Methadone clinics (120 or so clients), in a small U.S. cities.

Also, please pardon any apparent randomness in the flow of these discussions until I’m able to develop a logical, coherent information presentation system. Please feel free to communicate any topics which you would like to be discussed/have commentary/opinion on and I’ll try to do so in a timely fashion. Remember and be aware that what I say or claim here may not be so or applicable at another or your clinic. All Opioid Treatment Programs (OTPs) (Methadone clinics) adhere to the same Federal guidelines but State and Local guidelines and ordinances vary and as in all aspects of medicine, practices vary, especially in clinical areas where there are no convincing or accepted scientific or clinical studies to indicate one clear clinical pathway. Always confirm what you read here by doing your own personal research.

Methadone Maintenance Therapy (MMT) for Opioid Use Disorder (OUD) (opiate addiction) has been around (approved) and practiced since the 1970’s, in this country (USA), and has the longest track record of any widely used medication-assisted therapy (MAT) for OUD. It is still somewhat stigmatized for various fallacious reasons. I hope that this effort can pull back the veil and shed more light on this magnificent, life-affirming treatment option.

MMT combines a type of pharmacotherapy called, “Opioid-Agonist therapy” (OAT) or Replacement Therapy, so called because it consists of using Methadone (a long-acting opiate agonist), to replace the client’s illicit daily opioid use with a legally sanctioned (replacement) opioid, in order to prevent the onset of acute opiate “withdrawal” (the “Abstinence syndrome”) and so maintain a feeling of wellness while counseling/behavioral/psychological techniques are simultaneously applied, in addition to drug use monitoring. All in an effort to induce favorable behavior changes, primarily, abstinence from illicit drug (opioid) use/abuse, the maintenance of sobriety (remission) and to promote the development of a new lifestyle of “Recovery” from the addiction.

Other (non-methadone) pharmacotherapeutic options for medication-assisted treatment of OUD do exist. These include using an alternate opiate-agonist called Buprenorphine (generic name) or employing an opiate-antagonist medication instead, such as Naltrexone (generic name). Only medications which have been approved by the FDA (Food and Drug Administration) for this specific purpose (OUD treatment) are allowed to be used. Agonist and Antagonist medications cannot be used simultaneously. Remember that while in/on opiate-agonist MAT the client/patient is still opiate-dependent, that means that their body still requires daily exposure to opiates in order to function as “normal”, in other words, for them not to go into “withdrawal”. Antagonist MAT can only be considered after someone (the opiate user) has been free of opiates for an extended period of days to weeks.

In my opinion, what makes MAT in the OTP (clinic) setting so successful in breaking the cycle of opiate addiction is it’s completeness. The avoidance of the pain of “withdrawal” from acute/immediate “detoxification” (forced, complete, abstinence from all opioid exposure) combined with the strict rules/restrictiveness (witnessed treatment drug administration)/personal accountability through in-house (one-stop) counseling and frequent drug-use monitoring, are all crucial aspects of these programs. The program provides a stepping stone/training wheels, in the form of professional assistance on the path to ultimately achieving total abstinence from illicit opioid use and opiate independency (after the weaning (medically-supervised withdrawal) process of getting off the treatment opioid), gradually, after several months or years of re-building one’s life, while in the program. This establishes an extended period of monitored sobriety in a new Recovery lifestyle before embarking on the lifelong journey of maintaining this sobriety unaided by opioid medication.

Keep in mind that this therapy, as with many other treatments/techniques for managing chronic medical illnesses, may need to be reapplied (voluntarily), in the event of imminent or established relapse (a return to active illicit opioid drug use). OUD is a chronic, relapsing, progressive brain disease with no known cure and so relapse is to be planned for and accepted, however, it is to be avoided, if at all possible, by seeking treatment immediately, such as readmission into MAT, in a clinic (OTP-methadone) or office setting (Buprenorphine), especially following incarceration, or in-patient services/therapy. Some client/patients may choose to be on MAT indefinitely, if they’ve failed multiple attempts at medication-free sobriety but are able to manage their addiction favorably while on MAT-clinic or office and prefer it’s relative safety.

Photo by eberhard grossgasteiger on Pexels.com

That’s all for now. As you can see this is an extensive subject with many areas of controversy but what isn’t controversial is that this treatment option has been validated to be effective (for some) and has saved and rehabilitated countless numbers of lives . I’ll try to post soon on another aspect of MMT life. Thanks for reading and your feedback is appreciated!

PS: Here’s a link to an informative post on Methadone treatment for opioid addiction: https://www.thefix.com/7-things-you-need-know-about-methadone-treatment

Stu (Dr. P)

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