I know. Nothing brings out the boo-birds like a negative story about methadone. For the record I agree that methadone treatment, properly provided, is a vital and life-sustaining weapon against opioid overdose deaths. But too often, methadone treatment can become a lifetime curse.
This is long because the story is complicated. In this first piece I will describe the problems I saw in the methadone treatment industry. In the second I will offer suggestions for improvements and advice for any person seeking methadone treatment. In the third I’ll describe how buprenorphine treatment differs from methadone, and explain why doctors in methadone programs have strong incentives to push people toward methadone over buprenorphine. I’m not trying to throw the baby out with the bathwater; if you are addicted, a methadone program can save your life. But read my next post so that you can take steps that will allow you, eventually, to leave treatment.
I treat psychiatric and addictive disorders. I saw the immense value of buprenorphine almost immediately and got my buprenorphine waiver in the early 2000’s, before I completed psychiatric residency. I currently treat about 265 patients with buprenorphine. I worked in methadone-assisted treatment for about six years, up until 2020, long enough to see the best and the worst parts of that industry.
Most people have heard of methadone-assisted treatment, but few people — few doctors, few politicians, few parents, and few people struggling with opioid use disorder — know how it is practiced. It is an area where regulators assume that the companies involved know what they are doing, and the goal of regulators is to keep a program running. Nobody ever steps back to look at the big picture and ask ‘are we doing the right things to help these people?’
I was approached in about 2015 and asked to be the medical director of a new methadone program. Before committing I travelled to Ohio to observe a clinic, meet with the company medical director, and see how things were done. I was told that the company did not allow methadone doses to exceed 100 mg, an important issue that I’ll get to. That assurance turned out to be false, but in the end I was allowed to run the program however I thought best, so no big deal.
Methadone dosing IS a big deal to methadone advocates. Any read of the literature will explain that a dose of 60 mg/day is sufficient to prevent overdose and withdrawal in most patients. Some people claim that the fentanyl problem warrants higher doses of methadone, but I don’t see the connection (they claimed the same thing ten years ago saying that growing heroin use over pills warranted higher dosing). Neither argument holds water. If 60 mg prevents relapse, the nature of the abused drug doesn’t matter. And beyond that, the danger of fentanyl lies more in the drugs lipid solubility, not the dose — which addicts generally account for by starting low. Believe it or not, most opioid addicts are not hell-bent on killing themselves. Most take precautions about dose. They don’t, however, have a way to prevent the apnea that follows use of a highly-lipid-soluble opioid like fentanyl analogs.
Continuing the thought…. if methadone clinics are serving methadone to patients who are also using heroin and fentanyl, maybe a higher dose is good. Of course, if they are taking those drugs on top of the high methadone doses, isn’t that a recipe for disaster? And isn’t the point of methadone to promote abstinence from illicit opioids? When you think it through, there is no pharmacologic excuse for larger methadone doses.
Some articles in the literature refer to ‘high-dose methadone’ as doses over 100 mg. To skip to the punchline, many corporate methadone clinics have patients on doses of 200, 300, 400, and even 500 mg of methadone per day.
The medical directors of corporate methadone programs are bright people. I have met several, and I’m always impressed by their knowledge. But the ones I’ve met seem to have limited control over company culture. CEO’s have good reasons to keep doses high, and medical directors answer to them.
The biggest addiction treatment societies are the American Society for Addiction Medicine or ASAM, and the American Association for the Treatment of Opioid Dependence, or AATOD. ASAM generally consists of a wide range of topics including basic science, counseling, abstinence-based and medication assisted treatments, and legislative issues related to addiction. AATOD, on the other hand, is dominated by methadone.
In the past, state legislatures have tried to place limits on methadone dosing. Those efforts created a backlash that exists today in ridiculous form. At my first and only AATOD meeting, a lecturer asked the audience of mostly counselors and therapists, ‘what should be the limit on methadone dose?’ To my horror, the crowd began chanting ‘no limit! no limit! no limit! These were people without any significant medical knowlege – no knowlege of long-QT syndrome, for one example – who were indoctrinated into practice patterns unlike anything described in the literature, or anything outside of methadone programs.
When I began working with methadone, I worked with a small, family-run company. I could easily call the owners and others in the ‘chain of command’. They focused on quality, and hired a great crew of nurses, counselors, and staff. The director was an ex-marine with years of experience treating addiction. I quickly felt lucky to work with such a great crew. We all felt the same way — that while methadone is an essential treatment tool, it shouldn’t become a lifetime crutch for most people. Every week at staffing we discussed the length of time a patient had been in treatment, whether the patient was improving, and the appropriateness for taper and discharge. We discussed methadone dosing, and whether a patient’s request for a dose increase was likely pharmacologic or the result of life circumstances. If you believe those discussions are typical, you have no idea of how most programs are run.
Patients entering treatment are scared to death of withdrawal. They typically worry that the statutory dose of 30 mg, or a daily total of 40 mg, will not be enough to prevent withdrawal. Methadone accumulates over time so the initial dose is not sufficient to suppress withdrawal in some people. But many patients returned to say “wow, that is amazing. I didn’t feel sick at all until this morning.”
But even those patients, with assurance that their blood levels of methadone would rise from there, ask for a dose increase. “I think a little higher would be better.” And of course that’s what they would say– they are untreated people with opioid use disorders after all! I was quickly aware that virtually all patients enter treatment with ‘opioid hunger’ — a sense that more opioid is good, and less opioid is bad. That sense reverses later in treatment. But by that time, it is too late to escape from methadone-assisted treatment.
At our program, the average methadone dose was 93 mg/day. We measured the metabolism of our patients, and some patients metabolized methadone more quickly than others. But as with all opioids, tolerance develops to ANY dose of methadone. I had a couple patients on doses up to 200 mg/day, usually women who were metabolizing the drug more quickly during a pregnancy. But after delivery we worked to get the dose back down so it wouldn’t climb higher with the next pregnancy. Unfortunately many of the patients at our program were single moms with some kids at home and others ‘in the system’.
It isn’t just pregnant women who experience dose escalation, and the reason is both simple pharmacology and corporate greed. Methadone is so cheap that it hardly makes up a cost item for methadone clinics. Drugs like heroin, methadone, and fentanyl are agonists that cause tolerance. If a person takes the same dose of an agonist each day, tolerance removes much of the euphoria and other effects from the agonist. The only way to keep the warm and fuzzy feeling going is to steadily take doses that are higher than one’s tolerance — a process of chasing one’s tail forever.
In the using world, other factors eventually stop the increase in tolerance. Finances limit the amount of heroin a person can use. Or the addict eventually commits to keeping things where they are rather than digging a deeper hole. At that point life rotates between episodes of feeling ‘normal’ and feeling sick. Any hope for euphoria is long gone.
But in a methadone program, dose increases are there for the taking. Patients are allowed almost any dose that they ask for. Understand that with agonists, the primary effect of the drug is subject to tolerance, but some side effects are not. People on methadone tend to become more and more drowsy at higher doses. And the higher the dose, the less likely a patient will ever escape methadone treatment. That’s the greed part. CEO’s tell themselves that all of their patients should be in treatment forever. How else would they sleep at night? But then why have 2/3 of my Suboxone patients moved beyond treatment and tapered off, and now grow their careers off opioids? Why do most people do well after three months in good residential treatment? Is methadone-assisted treatment truly successful if nobody can ever leave?
I tried my best to convince our patients to avoid dose increases. I educated the counselors at our weekly meetings so they were less likely to tell every patient with anxiety ‘maybe you need a higher dose!’ Those who listened to me, a year later, often told me how grateful they were for my advice. Those who didn’t are still there, and will likely be there for the rest of their lives.
Detox from opioids is difficult and painful. In general, the higher the tolerance to opioids, the more severe the withdrawal. A typical heroin addict has an opioid tolerance equivalent to about 60 mg of methadone per day. A person on buprenorphine (aka Suboxone) has a tolerance equal to about 35 mg of methadone per day. A person on 400 mg of methodone has a tolerance that is about ten times greater. Why? What’s the point?
My nice little methadone program was eventually bought out by a much-larger company. Things changed. I won’t get into specifics about that company, but I have worked in the industry long enough to know that my story applies to all large methadone treatment corporations.
The big companies do not make any significant effort to keep doses of methadone reasonable. Yes, there are a few docs out there who try their best – but they are not going to win awards from management. Why would companies give patients so much methadone knowing that tolerance will remove the effects of every dose increase? Anyone who understands pharmacology knows that the enzymes that metabolize methadone are not limited. No dose reaches a ‘saturation point’. Whether a person takes 160 mg methadone/day or 300 mg methadone/day, the forces of tolerance will eventually make the two doses feel the same. Methadone docs twist the data to claim that higher doses last longer and are needed in ‘fast metabolizers’, but that doesn’t make sense pharmacologically. Half-lives are half-lives; they are not ‘dose-dependent’. The blood level of methadone, in a person with a 12-hr half-life, will vary from 100 to 50, or from 400 to 200. In each case, tolerance is near the midpoint of each range. Raising a dose will fix the problem only temporarily, and when the dose is held constant the patient will feel the same at either dose.
Patients will retort ‘it didn’t work for me until I got to 300 mg/day!’ To that I would point out that by that time, you also had a year or more in treatment — going to the clinic 6 days per week for the first few months and maybe every single day, the entire time, if you used THC. Maybe treatment helped?
I still see many of my old patients but for psychiatric complaints. Most have attended the clinic for 6-7 years and have no end in sight. Discussions of ‘the clinic’ usually lead to despair. “I’ll never get out of there!” they say. Most are marginally employed. That’s only natural since private insurance often doesn’t cover the $500/month charge of endless methadone administration, and medicaid does. Medicaid even offers a ride to the clinic. So patients have a very strong reason to avoid getting a good job, as that would cost $500/month and require a car.
It typically takes a year to taper off 50 mg of methadone. A tolerable rate is about 2% every week or two. Patients often will try to go faster, and ask to drop their dose by 10%… but the blood level of methadone adjusts over about a week following an adjustment, and tapering too fast only leads to ‘yo-yos’, up and down with dose. A slow and stead taper will get a person off 100 mg of methadone in a couple years– providing there is no crisis that causes the patient to ask for a dose increase ‘just this one last time.’
Doctors at clinics don’t make it easier. My patients tell me that even after the explain all of the reasons they want to stop, they are constantly offered higher doses. They describe tapering for years, starting at 120 mg, getting down to 80 mg after weeks and weeks of hard work and insomnia, then going back to 120 at the doctor’s suggestion. Even after six years of treatment, a patient with opioid use disorder can only say no so many times.
Tapering from 200 mg/day requires many years of everything going well. No moments or episodes of depression. No setbacks in life that always stop a taper and cause a dose increase. Tapering means years and years of minor withdrawal, day after day. Could you wake up after a month of restless nights feeling depressed and sweaty each morning, and say ‘no’ to a doc’s offer of instant relief?
Why would a ‘treatment program’ push higher and higher methadone doses on their patients, knowing that tapering from 200 mg/day is almost impossible for most people?
A couple Wisconsin doctors started a group of methadone treatment programs in the early 2000’s and eventually sold their five clinics. I don’t know specifics but the number everyone talked about was $53 million for those clinics. Clinics have between 200-800 patients, each charged about $500/month. Maybe medicaid gets a discount; I didn’t know the books. But either way, we are talking about a lot of money — money that depends on patients sticking around. Get a patient on 200 mg methadone/day and you have that person for the rest of his/her life.
The tragedy is that most of those patients live in poverty, afraid to take one of the many general labor jobs in my area that start at $22/hr and quickly run higher. If their urine tests positive for THC, they must attend the clinic six days per week. Even if they don’t, one false-positive from a poppy-seed muffin starts the process all over… one day off for a few months, then two days for a few months, etc. No leaving the area for a long weekend. And no moves to better opportunities unless that community has a methadone clinic.
Dole and Nyswander, pioneers of methadone in the US in the 1960’s, stated that some people would prefer that addicts spend their lives in institutions rather than experiencing the freedoms offered by methadone. I think that in a world of corporate methadone treatment, people should start asking which ‘institution’ is keeping them enslaved.
I’ll add that my own addiction to fentanyl, which I’ve discussed many times on earlier pages, was treated in 2001. I’m so grateful to have left all of that in the rear-view mirror… If I had been ‘tapered up’ to 300 mg methadone I’d likely still be stuck in a program — and certainaly not working in the medical field.