I described how seeking methadone-assisted treatment for OUD can lead to a lifetime dependency. Informed patients can take steps to reduce that risk of life-defeating attachment. Clinics could do the same, although doing so may harm the business model of some companies. People entering treatment, follow this advice so you don’t spend a lifetime in treatment.
Patients:
The message for patients is simple: avoid repeated dose escalation. Understand that tolerance will develop to any dose, whether that dose is 60 mg methadone/day or 300 mg/day. It is true that after every dose increase you will feel a slight boost in opioid effect that will last a week or so. It isn’t worth it. I know that boost is hard to say no to, especially early in treatment or when you’re going through hard times. But as you gain control over your addiction, remind yourself about what you already know about tolerance. The effect will be short-lived, and painful to reverse. You have made the smart decision to turn your life around, so don’t let anyone steal if from you. Every increase in dose is one more link of attachment to the clinic. Get what you need, and avoid using more.
When I worked in the industry (and it is an industry), we kept doses low. Many of our patients stopped dose increases at 40 mg/day. Some stopped at 60 mg/day. Most of those patients have since tapered off methadone after spending 2-3 years at the clinic. Those patients are now able to hold good-paying jobs in the area. When they see me they thank me for discouraging them from using larger doses, and talk about their relief to be free from the clinic. Those who went higher are still there after 6-7 years, and most of those people will be dosing at the clinic for the rest of their lives.
My relationships with these two groups of people, by the way, are what prompted me to write this series. I realize I won’t likely work in a methadone program again after sharing my experiences. But I can’t imagine working for one of the bigger companies given what I know. If I ever return to the industry it will be with a group of like-minded people who understand the potential harms associated with such programs.
Back to patients, the doctor at your clinic will likely encourage you, repeatedly, to raise your dose. That will be the fix for any complaint or mood swing: “I think you need an increase.” Understand that many clinic directors are tasked with raising clinic numbers. Their performance reviews rely on it! They do not get awards for allowing patients to exit treatment, so look out for yourself. Nobody else will.
Just as important. Take your time on methadone seriously. Use it to get your act together. One problem with methadone treatment is that ‘recovery’ is a SLOW process for so many patients. People who enter a 90-d program generally run on all cylinders after 3 months, with 90 days of sober time and huge improvements in physical condition and mood. In a methadone program, abstinence isn’t required, at all, even after three months. They will allow you to flounder for years. Again, it is up to YOU to make it work.
Remember, the longer you put off getting it together, the more trapped you will become… since the primary ‘tool’ used to fix you will be raising your tolerance and pushing your dose. If you are still struggling with withdrawal and cravings an increase might help. But write down your response to help you remember. If going from 60-75 mg doesn’t help, and going from 100-115 mg doesn’t help, raising your dose further is unlikely to change things. The saddest cases are the patients who metabolize methadone relatively quickly and raise their doses very high at the doctor’s suggestion, thinking it will help. It won’t. Half-lives are not dose dependent. You will end up stuck on a ‘treatment’ that makes you feel horrible every day, and the only solution will be to somehow detox when you are already struggling from withdrawal.
Do what you can to get take-homes, meaning do your callbacks, stop THC and other drugs, and follow the rules. Do not eat a poppy-seed muffin as that can set you back for months. If you have more questions, join the community on my forum, where you’ll meet others who have been on methadone.
Clinics:
I have no expectation that clinics will change given the profit incentives of keeping things as they are. People with a loved one on methadone probably think that ‘treatment’ will have a beginning, a middle, and an end. That is not the case in methadone programs. Most programs spend little if any time pushing patients toward eventual discharge even after many years. Clinics should, of course, spend a little effort helping people move beyond methadone. As Dole and Nyswander pointed out, people should not be stuck in an institution for life as a result of their addiction.
Clinics could also do more to advance the lives of their patients. Most people on methadone must maintain Medicaid, meaning that advances in employment pose a risk. Many of the patients I met over the years are still unemployed or underemployed, or working ‘under the table’ in lousy jobs with no benefits. Clinics should do all that they can to join insurance networks to reduce the cost of treatment, which is over $5000 per year in Wisconsin.
The unemployment fostered by clinics creates poverty, and poverty leads to other problems. Families struggle and break apart. Patients are allowed to struggle almost indefinitely, eventually leading to state actions that cause a parent to have some children at home and others in foster care. Does that sound like a recipe for a happy life?
Methadone programs try very hard to stay outside the realm of organized medicine. Sometimes the only connection to ‘medicine’ is the name of the company. The result is that most physicians know nothing about methadone-assisted treatment. The clinics like it that way, because most doctors would shy away from referring patients to a lifetime in a clinic.
Methadone-assisted treatment should be administered consistent with studies in the literature. Those studies claim that treatment requires about 60 mg of methadone/day, sometimes up to 120 mg/day. In my area, clinic doctors are not subject to intervention by medical boards, who seem to assume that all of those doctors know what they are doing. Shouldn’t a doctor have to explain why he is administering doses to patients that are 5 times higher than doses described in the literature?
I’ve written about the recent changes in the CDC’s 2016 recommendations on opioids and pain. How ironic that patients with severe pain, who have never abused their medication, have arbitrary limits on the amount of opioid relief they can obtain. Yet patients who have abused, bought, and possibly sold illicit opioids are encouraged to run doses to the sky. Some of those patients are given take-homes with potencies that are orders of magnitude greater than those considered appropriate for pain. For example, a patient on 300 mg methadone per day can get take-home doses of methadone totaling up to 4200 mg every two weeks. Patients on pain treatment are generally kept below about 60 mg of methadone per day in divided doses. So, in one month the pain patient is prescribed up to 1800 mg of methadone. The addiction patient receives 8400 mg to take at home. In what world does that make sense?
Agencies promoting methadone treatment, like AATOD, should spend less time chanting about unlimited methadone doses and more time teaching practitioners how to move patients beyond treatment. Perhaps doctors who treat patients with buprenorphine could help them with that issue. Don’t hold your breath on that!
Regulators:
States have agencies with authority over methadone-assisted treatment. In my six years, I never heard a peep about moving patients beyond treatment. Successful completion of treatment should be the gold standard. Having patients in treatment beyond five years should raise questions about treatment efficacy. Does it truly require five years to treat a person with opioid use disorder? My own addiction, in 2001, responded to three months in residential treatment. I couldn’t believe how great I felt after my discharge! I had the benefit of state monitoring in their standard 5-yr physician’s program. But 90 days was sufficient to provide a start in recovery and perspective on my illness. Some people likely require more help, but a huge part of recovery is gaining self-esteem by interacting with society, working a job, and becoming economically stable. Too often patients in methadone-assisted treatment experience none of those things, through no fault of their own. Instead, they become more and more discouraged by their inability to break free from the clinic. State agencies should follow the progression of treated patients into the workforce, reduction in patients’ children ‘in the system, and similar metrics.
Someone will ask about the difference between methadone-assisted treatment and buprenorphine treatments. I will get into those differences in my next post. Some of the differences in patient course and outcomes result from differing payment systems and regulations. But patients who present to both treatments are similar, and the differences in outcomes, at least in my area, are too large to attribute to regulation alone. I believe some of the outcomes at clinics would improve if methadone clinic doctors were held to the same standards as other doctors.
Doctors in methadone programs fly under the radar. The death of a patient in a methadone program is a matter for the state methadone authority, which may respond by placing limits on a clinic’s ability to accept new patients for a period. The program is held accountable, but not the doctor who ordered the administration of methadone. Many states allow nurse practitioners to provide medical management of methadone clinics. Any supervision for most of those nurse practitioners is through email or telephone calls. Yet they are administering amounts of take-home methadone that could kill several people with one dose alone. Where is the oversight?
It is rare for me to write something that hasn’t been written before. This may be my first time. I believe that the reason for the absence of negative articles gets at the basic problem with methadone-assisted treatment. The patients who are stuck in those programs do not have a voice. State agencies that regulate programs develop close relationships with representatives from the businesses in the industry, but rarely spend time with patients of the industry. Frustrated patients vent to me at their appointments, and express fear that the clinic might retaliate against them by taking away their take-homes if they cause problems. Many patients at the clinic lack computers or email because of financial constraints. It is truly a David and Goliath word where David lacks a good slingshot.
Why don’t patients stuck in methadone programs change over to Suboxone? They could then see any of a growing number of physicians in communities across the country? They could get prescriptions at office visits, just like patients with any other illness. Visits could be spaced out at frequencies appropriate for each patient. In my next post I will explain the advantages of buprenorphine treatments, and how methadone-assisted programs make such transfers almost impossible.
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