My usual disclaimer applies – this is just my experience and understanding. I’m not a doctor, I just play one on TV. Actually, I am a doctor, and I don’t play one on TV, but my opinions are my own and my understanding skewed by my juniour-ness in the profession.
Part of my recent psychiatry rotation saw me spending one morning each week in a local Methadone Maintenance Therapy (MMT) Clinic. Methadone is a synthetic NMDA/Opiate agonist, developed in early Nazi Germany, and has been in regular use longer than you’d think.
Those of you from inner city neighbourhoods and especially my friends and colleagues who have worked in the Downtown Eastside of Vancouver will know the Methadone program well. In the mid 1950s in New York, MMT gained ground. It even involved production of the following comic book:
Methadone is used in addictions medicine and for chronic pain management. It is also useful in palliative care for patients who need less frequent dosing or who are unremittingly confused/delirious on other narcotics, since it has a unique half-life and does not carry the exact side effect profile as some of the other opiates. I want to talk more about the addictions side of things since that is what my recent learning focused on.
Methadone Clinic, First Visit:
When used in an MMT (methadone maintainance therapy) setting, there are strict rules governing how the drug is administered. Usually, a person comes into the system after referral from a friend, doctor, or when they themself have accepted the need to change. They meet with a doctor who has a special licence to prescribe – though technically, it is a licence not to be prosecuted for dispensing an illicit substance. First visits are good times to screen for other drug dependence (cocaine, alcohol, and benzos are often in the mix). One can also acquire a bit of a medical history, and screen for things like Hepatitis C, as well as learning about the rich psychosocial aspects of a patient’s life. Depending on their situation, we may recommend referral to Social Work or to the Mental Health Team.
Methadone Maintenance Process:
Initially, a patient will be started on a once daily dose, a very low dose, and over a period of weeks, titrated up to a therapeutic level. We treat cravings and opiate withdrawal symptoms. Some patients will say that they are really sweaty, so they need more methadone, but unfortunately it is probably a side effect of the treatment itself. The patient keeps returning, and we check in to see if they have a stable living situation, a job or other source of income, supportive relationships, etc. We ask if they are using narcotics or other drugs. They give us urine samples to prove that they are not using other drugs. If their lives begin to stabilize and they are not using, they may be given “carries.” No, these are not cavities (“caries” in dentalspeak) but rather quantities of methadone dispensed from the pharmacy that may be taken home. If they don’t follow the rules, they are stuck on Daily Witnessed Ingestion (DWI). The hassle of having to get to the pharmacy on a daily basis is one of the motivators for people to ‘get their shit together’ so to speak.
Maintenance, or tapering off?
Once people reach a dose at which their addiction is treated and the side effects minimal, they may plateau there for some time. Maybe for a long time. Many wish to taper off eventually because of the attached inconvenience (even if they have 6 carries, they still have to go weekly to pick up the “juice”). There is also a stigma with methadone that many wish to escape, and to start their new life, they want to be 100% clean. Some very high-functioning individuals just don’t do well with tapers. They may be candidates for methadone pills, or a substitute (Suboxone), however, this is not paid for by the government and can be quite costly.
What is Harm Reduction?
You’ll see that I’m a supporter of “harm reduction.” This can be interpreted a few ways, but in my own mind, it is what it says: For example, even though we know that sexual abstinence is the only way to stay free from STIs and unwanted-pregnancy, the reality is that people will be having sex. I recommend contraception and barrier protection, like condoms, because abstinence may not be a practical solution in our culture. I recognize that condoms are not as successful as abstinence, but they are more likely to be utilized than is abstinence. We are not avoiding all harm, but we are realistically reducing harm.
Providing methadone to opiate addicted patients can improve their health and other wellbeing; even though abstinence from drugs might be even better in this regard, I am willing to accept a bridging measure (the Methadone) because total abstinence is not a realistic solution. Addiction is hard to beat. As my preceptor would say to a patient with addictions:
your brain was once a cucumber, now it is a pickle.
There’s no going back to before you tried that drug for the first time – you are wired to it. Your pleasure centres rattle with the thought of it. You ache without it. And your brain still wants it, even when your life is falling apart because of it. There are many barriers to get beyond that urge; fortunately, methadone is a great help.
That doesn’t mean that I think people should aim to be on methadone forever, but it offers a safe and practical pathway to better things. Some individuals will never be able to live off of it, and some will not be able to straighten out their lives whilst on it, but it certainly offers a chance for normalcy in those suffering.
Advantages:
With methadone maintenance in their lives, opiate-dependent individuals benefit in numerous ways. The program is an attempt at harm reduction, substituting something ‘less bad’ for the greater evil – in this case, heroin or oxycodone from the street and their associated ill-effects. It’s thought that by providing a safe, monitored narcotic replacement, we can reduce overdoses, the petty crime associated with trying to finance an illicit habit, and the rates of infectious disease transmission. At the same time, doctors and other health care workers can create a connection with marginalized individuals who might otherwise never encounter the health system.
Months or years of respect from a physician can go a long way; a patient who is disenfranchised may tell you about that funny mole on their back or the cough they’ve had for a while. Having built a solid relationship around MMT, a doctor can also aid a patient with other aspects of their health. Many of these patients have treatable, comorbid conditions like Hepatitis C and HIV, and will live better lives for having these addressed as well.
It feels good for doctors to see a patient down to single digit doses of methadone and eventually off the drug. Even in those who require continuous maintenance, there are huge victories. It is not uncommon to see a person regain custody of their children, find a new and comfortable home, form solid relationships, get on disability, get off disability, or find gainful employment.
Downsides
There are downsides. Over-sedation can occur and overdoses are a possibility; that’s why we use the ’start low, go slow’ methodology for dosing. Like any drug, methadone has some undesirable side effects. High doses may lead to profuse sweating. Long term therapy with opiates of any kind – including methadone- can cause things like constipation, and in the very long term, impaired libido and erectile dysfunction (via suppression of GnRH in the pituitary). There is a major stigma attached to methadone, and people treat methadone patients differently. Often, they are treated like shit, even by health care ‘professionals.’
Unfortunately, Methadone is also drug of abuse, for the little high it can generate at such a low cost. This is part of the motivation for the DWI program; if a patient must ingest their medication in front of a pharmacist, they cannot turn around and sell it on the street. People with addictions do play a role in the choice to get better, but sometimes, their desperate need to use (other drugs) can overcome whatever bit of willpower they have retained. It’s very difficult for an addict to earn trust, but it is possible.
Bullshit!
One of my favourite parts of working in the Methadone Clinic was being able to call people on their bullshit. Some describe the life of an addict as “living the big lie.” They know it, I know it, so let’s not be naive! The pathology of addiction does not allow a person to be honest with themself, and if they have been beg/borrow/steal-ing to maintain the habit, those are tough patterns to break. But methadone does help. And so does seeing that someone (like a doctor or nurse) is invested in your recovery.
Urine testing is one way that a person can prove their progress. The privilege of ‘carries’ will be withheld if the patient provides a dirty urine; this means, their urine shows traces of other drugs or a lack of methadone metabolites.
My patients and preceptor gave me lots of tips about interpreting urine tests. Pee in a cup, and we will discover many delightful and amusing things:
Urine Shows Patient has told me: Actually… no methadone metabolites “I forgot today’s dose” Not taking their methadone, it’s someone else’s urine or water; patients are dependent on this substance, so it is unlikely that they wouldn’t have had their dose (esp. in our clinic as it is right beside the main methadone-dispensing pharmacy)even if they missed their dose, there should still be metabolites in urine from prior doses other opiates or oxycodone positive “I’m not using”“I had a headache. My friend gave me a Tylenol. Maybe it was a Tylenol with codeine? I don’t know, I don’t even want that stuff.”“maybe a few weeks ago, I might have had an oxy”
Oxycodone requires a special assay; if that is positive, they are definitely using oxycodone!However, if the opiates are positive, that could include heroin, morphine, codeine, etc. cocaine positive “It’s okay, that’s just a party drug. I use it, like, once a month. It’s not like I’m addicted to it or anything. Why can’t I get Methadone carries anyway?” Ccocaine use! Polysubstance dependence is not uncommon, and recreational drugs all have effects on a common neuropathway; a condition of gaining the privilege of carries is that they are clean from all drugs Benzodiazepines positive “I take it for sleep”“Oh really, I don’t know how that could’ve got in there.” Might be on a benzo sleeping pill, should not be! There are very few legitimate uses for benzodiazepines.Lots of addiction here, and cross-dependence with alcohol. Canabinoid Positive “yeah, I smoke pot”“I haven’t smoked up in ages” Probably telling the truth. Metabolites can last for longer than 30 days in certain individuals.Might be on nabilone, esp if their Methadone is for chronic pain Amphetamines Positive “Oh, yah, I had some cough syrup for my cold” “You said that last time. Remember how we talked about how cough syrup is ineffective anyway? Sorry, no carries for you until you stop this stuff. How can we help you kick the amphetamines?” Cold urine “hmmmmm” Tap water, someone else’s urine Blue-tinged urine “yah, maybe… I didn’t want to give the uhm urine” This is toilet water! Some clinics that dose a lot of methadone put blue dye in the toilet so that this can’t be usedThis wikipedia chart about how long drug metabolites appear in urine/blood&saliva/hair should be study material for every doctor and addict alike!
Some patients will try to tell you that they are rapid metabolizers and will require taking methadone twice a day rather than once a day. While this is a rule in pregnant women, it applies to only a small section of the regular population. The half-life is variable from patient to patient, but at the same time patients may have an ulterior motive for requesting twice-daily dosing. It’s challenging to figure out which is the legitimate complaint and which is someone trying to abuse the system. Luckily, we can say “there’s a test for that!” We compare peak (4 hr after dose) to trough (just before dose) serum levels and see if they truly are rapid metabolizers. This is important because too much methadone can be a bad thing; I’ve seen patients admitted to hospital, dosed at the amount their prescription record shows. By day 2 they are totally sedated – this is because they have not been taking all of their methadone in the community, usually selling the extra dose. Dangerous.
Being a hard-ass can be fun. It’s not difficult to know when you are being scammed, but you get used to it and start to enjoy calling people on their BS. Being blunt with a patient shows them you aren’t afraid to be honest – and it asks that in return for your efforts to help them, they will respect you with honest discourse. Only if both the doctor and patient are honest with each other can treatment achieve success, as defined by either party.
I really want to incorporate methadone-prescribing into my practice in the future. If you thinking of doing the same, develop a firm policy of universal precautions and stick to it. Enjoy watching your patients do well, because so many of them will.
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