Who Should NOT Be in Medication-Assisted Therapy with either Methadone or Buprenorphine?

addiction cartoon

I spend much time and effort explaining how medication-assisted treatment for opioid addiction works for many addicts. It occurred to me that I should explain who isn’t a good candidate for such treatment.

I enthusiastically support medication-assisted treatment (MAT) of opioid addiction, but no treatment works for everyone. MAT doesn’t work for every opioid addict. Here are some reasons a patient may not be suitable for MAT:

1. The patient isn’t addicted to opioids. That seems obvious, but occasionally I encounter an addict who wants to be started on methadone even though he’s not addicted to opioids. Rarely, an addict using cocaine, benzodiazepines or other drugs will come to the OTP after they have heard how well it worked for other (opioid) addicts. After I explain that buprenorphine (Suboxone) and methadone only work on opioid addiction, some of these patients have become angry.

One patient accused me of discriminating against her because of the type of drug she used. I said yes, but only because methadone doesn’t treat cocaine addiction. (I tried to refer her for more appropriate treatment.)

2. The patient takes opioids for pain, but has never developed the disease of addiction.
Such a patient may be physically dependent, but lacks the hallmark indicators of addiction, such as misuse of medication, obsession and compulsion regarding opioids.

Opioid treatment programs, (OTPs) have stringent regulations put on them by both federal and state government, because OTPs are designed to treat patients with addiction. These patients have lost the ability to control their intake of opioids, so the OTP regulates a maintenance dose of either methadone or buprenorphine to keep the patient out of withdrawal and able to function normally.

If a patient has only pain and no addiction, there’s no reason to enroll in an opioid treatment program, because patients without addiction are still able to take opioid medication as prescribed. Pain medication can be prescribed by any doctor with a DEA license.

Opioid treatment programs aren’t intended to treat chronic pain, but if a patient with both addiction and chronic pain finds methadone also helps with pain, it’s a nice benefit. Many of these patients do find they have less pain once they’re out of the miserable cycle of intoxication and withdrawal. So less pain is a happy side effect of addiction treatment.

3. The opioid addict presenting for treatment has been physically dependent for less than one year.
Methadone is difficult to get off of, and federal and state regulations say it cannot be prescribed for opioid addicts with less than one year of addiction (daily use or near daily use). This is a somewhat arbitrary cut off, and the OTP physician can ask for an exception to this regulation if needed. Even if the OTP wants to treat the patient with buprenorphine (Suboxone), which is usually much easier to taper off of than methadone, permission must be sought from state and federal authorities before enrolling a patient who has used opioids less than one year.

If buprenorphine is prescribed in the office setting, the prescribing physician can use her best judgment about who is appropriate for treatment, without needing government approval.

4. The opioid addict has the ability to go to a prolonged inpatient residential treatment program for his addiction.
This is controversial, because some doctors think medication-assisted treatment should be given to everyone because of its success rate compared to abstinence-only treatments.

But who gets the best of medical treatment in our country? Possibly it is medical professionals like doctors and dentists, airline pilots, politicians, and celebrities. They usually get the gold standard of treatment for whatever disease ails them.

If such people have opioid addiction, they are treated with inpatient medical detox, using buprenorphine to ease withdrawal, followed immediately with prolonged inpatient residential drug addiction treatment. I know doctors and dentists who spent six to nine months in treatment. After treatment, they must sign monitoring contracts with their licensing boards in able to go back to work. These contracts usually involve a mandated number of group sessions per week and random drug testing. With this kind of support and accountability, these medical professionals have excellent outcomes. Studies show that more than 80% are still off all drugs and alcohol at five years after entering treatment.

If only everyone could get that kind of treatment!

If this kind of treatment is available to the addict…take advantage of it. But most opioid addicts can’t access this kind of treatment, with post-treatment accountability. Insurance companies might pay for a one-week stay in detox, which won’t help. Even if the addict gets a few weeks of inpatient treatment, it’s usually not enough. What I’m talking about is months of quality inpatient treatment.

5. An opioid addict who is also physically addicted to alcohol, benzodiazepines or other sedatives. These drugs can be deadly when mixed with methadone or buprenorphine. I prefer such patients enter a medical detox unit to get off these sedatives prior to entering treatment in an OTP.

Of course this is a complex issue, and there may be times when starting methadone or buprenorphine can be done, perhaps keeping the patient at a relatively low dose, while the patient undergoes a gradual taper from benzos. The OTP physician should be free to use her best judgment about how to treat these complex and high-risk patients.

6. The opioid addict also has acute, severe mental illness. An actively suicidal patient is too sick for an outpatient opioid treatment program. So is an acutely psychotic patient who is having hallucinations and delusions. These patients often can’t to understand what is real and what isn’t. Ideally these patients need inpatient treatment at a facility that will treat both mental illness and addiction. Sadly, it’s getting ever harder to find such facilities for patients who need them.

7. A patient has behavior that interferes with treatment.
OTPs have an obligation to all their patients to maintain a safe and orderly treatment environment. Patients who start physical fights, threaten staff or other patients, or sell drugs shouldn’t be kept in treatment. I know that sounds harsh, but OTPs have a hard enough time maintaining good standing in their communities without having to face accusations about illegal behavior on premises.

Patients need to be emotionally stable enough to conduct themselves in a non-threatening manner to be able to remain in treatment. Some patients, after being counseled about acceptable behavior, are able to comply with requests for behavioral changes. Some patients have erratic behavior due to mental illness, and shouldn’t be blamed, but their behavior still may be too disruptive for the OTP setting.

8. The patient has serious co-existing physical health problems.
Actually, I can’t think of any physical health problem that would make the treatment of opioid addiction with methadone riskier to the patient than untreated opioid addiction. We know for sure that untreated opioid addiction produces high risk of death and disability.

Issues like severe lung disease and specific heart rhythm problems do increase the risk of medication-assisted treatment, especially with methadone. I try to contact the patient’s other doctors and consult with them before the patient goes above a low dose of methadone.

Ideally, I’d like to talk to the other doctors on the day of admission, before methadone is started, but that can’t always be done. With the time pressures doctors are under, it’s getting ever harder to claim some of their time for a patient consultation.

Some of these patients could be started on buprenorphine instead of methadone, which is safer with these health conditions, and has fewer medication interactions.

9. The patient has transportation difficulties.
Some patients can’t get a ride to their treatment program every day, which interferes with delivery of quality treatment. With buprenorphine, federal requirements for daily dosing were lifted, but states still have varying regulations. With methadone, the patient must come for treatment daily. During the first two weeks of stabilization, it’s important for medical personnel to be able to evaluate the patient every day, to assess the effects of dose increases.

10. A patient who enters treatment expecting to be completely drug free in the near future.
I try to make sure patients entering treatment with methadone or buprenorphine understand that I am not switching them from illicit opioids to these medications because tapering off of them is easier. Particularly with methadone, it is not. But both methadone and buprenorphine are so long-acting, they can be dosed once per day, giving the patient a steady level of opioids. This allows the addict to function normally, without withdrawal or impairment, once the dose has stabilized.

Both medications give the opioid addict time to regain physical and mental health. Once on a stable dose, the recovering addict can make changes in his life, with the help of counselors and other OTP workers. The addict can get back to work, stop a life of crime, form better relationships with his family and himself, and recover a better quality of life.

Will that addict ever do well off methadone? There’s no way to be sure about this. Some patients can taper off methadone, as long as they address all of their issues prior to the taper, and if they bring the dose down slowly enough that they don’t feel intolerable withdrawal. Some, perhaps most, recovering addicts find they will do better if they stay on methadone.

All this is to say that the goal of entering an opioid treatment program isn’t necessarily to
get off the treatment medication.

So if a patient seeks to enter methadone treatment but also expresses a desire to be off buprenorphine or methadone within weeks to months, I tell them their expectations aren’t realistic. These medications don’t work like that. If the patient wants to get off all medications quickly, they need referral to an inpatient program. This way, patients can’t later say they were mislead, and they feel like they have liquid handcuffs, chained forever to methadone, with its many regulations for treatment.

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25 responses to this post.

  1. Posted by Robin Robinette on January 5, 2014 at 5:33 pm

    Dr. Burson,
    A common misunderstanding of the regulations in apparent in # 3. OTPs CAN treat people who have been dependent less than a year; we are required to treat them in a detoxification modality, using either methadone or buprenorphine to reduce their tolerance and withdraw them within 30 days (“short-term detoxification”) or six months (“long-term detoxification”). The requirement of dependence on opioids for at least a year applies only to a maintenance modality – which is, of course, open-ended and patients can stay in treatment as long as it continues to benefit them.
    Many OTPs don’t do this and I am not sure why, but I feel a significant factor is that in 30 day detoxification, no take-home doses are allowed and therefore programs would have to be open 7 days, including holidays.

    Reply

    • Yes, you are right. I was talking only about admission for maintenance, sorry I didn’t make that clear.

      Reply

    • Posted by Angelo on January 11, 2014 at 5:45 am

      I guess you didn’t read or understand the whole context of number 3. He also said ” This is a somewhat arbitrary cut off, and the OTP physician can ask for an exception to this regulation if needed. Even if the OTP wants to treat the patient with buprenorphine (Suboxone), which is usually much easier to taper off of than methadone, permission must be sought from state and federal authorities before enrolling a patient who has used opioids less than one year.

      Reply

  2. I am particularly concerned with the young (teen to 25) age group of opioid dependent.
    Generally, I prefer to have them try non medication assisted treatment (except for as a reasonable gradual withdrawal aid ) first before risking lifelong dependency on methadone. Ideally, 6 to 9 month intensive residential treatment is the preferred first choice with consideration for a relapse and a return to a full time regimen. Subsequently followed by intensive daily outpatient and less than daily support treatment services coupled with support groups. This must be flexible and allow for an initial outpatient attempt, if desired, with the referral to residential treatment coming after repeated failures to maintain a healthy lifestyle free of dependency on substances. Clearly the harm reduction approach of methadone is essential but only after attempts at drug independency have been attempted.

    Reply

    • I have a problem with this “fail first” strategy, because opioid addiction is potentially fatal.
      Outpatient treatments for opioid addiction without medication such as buprenorphine, naltrexone, or methadone don’t work. Why send a patient for an initial treatment with little chance of success?

      Reply

  3. Dear Dr. Burson,
    All treatment for chemical dependence is subject to numerous incidents of failure or relapse. The methadone patient continues to use opioids until the effects are blocked. They also use numerous other substances, including alcohol, while receiving methadone and are highly susceptible to accidental overdose. All recovery is marred with slips and setbacks. Are you suggesting that methadone is somehow exempt from failure?

    I too did not believe that opioid addiction could be successfully treated in an outpatient setting without medicine assistance. But I was proven wrong, repeatedly, when addicts chose to work at recovery rather than face the consequences.

    Lastly, you did not specifically address my concern over risking life-long dependence on methadone with the youthful opioid addict. I am quite surprised at how easily you outright dismiss other approaches when no one has the silver bullet in treating opioid addiction.

    Your consideration is appreciated.

    Luke J Nasta, MPA CASAC

    Reply

    • No, of course I’m not saying methadone treatment is exempt from failure. No treatemnt works for everyone. I do have a problem with asking patients to go through a treatemnt, intensive outpatient program without medication assistance, that has little chance of success, instead of allowing that patient to enter an evidence-based treatment like MAT.
      IOP alone, without medication assisted treatment, is not an evidence-based treatment. Relapse rates are very high, in excess of 90% at one year.
      If you have peer-reviewed, published articles from the addiction medicine literature that says otherwise. please educate me.

      As far as young adults, as I said in my blog, if long-term inpatient treatment (3 – 9 months) is available, I’d go with that first instead of methadone. If the only thing you can offer is outpatient treatment, then I think those patients are better off going directly on methadone, preferable while they also do an intensive outpatient program.
      We don’t have silver bullets, no, but we do have an obligation to use evidence-based treatments, and not treatments that have little chance of success.
      Thanks for reading.

      Reply

      • Dear Doc.,
        Try being slightly less dismissive (and you might learn something). Is 28 day rehab evidenced based or based on the insurance industry’s allowable benefit ? The relapse rate for methadone patients is markedly less after 1 year – because they have reached the level of blocking the effects of opioids, they can no longer experience or feel the effects of opioids, therefore, why use? Please report the levels of continued abuse of other drugs and alcohol after 1 year to give a more accurate picture of overall stability and health.
        Am I to understand that you are of the belief that NIDA, SAMHSA, State Regulatory Agencies, AMA, Insurance/Health Benefits industries, etc. have been funding and reimbursing Outpatient counseling service for opioid dependent people for 5 decades without any evidence basis? The treatment field proceeds with an open mind in the hopes that some new methodology or combination of approaches may be most efficacious.
        May I inquire about your own credentials? How long have you been an opioid addiction treatment specialist ? I am beginning to understand why my colleagues introduced me to your BLOG.
        Respectfully,
        Luke
        ( I expect you will not publish this but you should be able to take as well as give)

      • I apologize for being dismissive. Just goes to show I shouldn’t write replies to comments when I’m in a hurry. I need to take time to be nice. Being nice is very important, because we have similar goals and need to be allies, even if we don’t agree on all things. I have every reason to believe that you are as passionate about your work as I am, so I am sorry to be dismissive.

        As for the data for patients on methadone regarding other drugs of abuse…studies are mixed, but here’s an excerpt from NIDA’s International Methadone Research and Web Guide: “Methadone Maintenance Treatment and General Drug Abuse—Among three cohorts of newadmission
        patients in methadone maintenance treatment, Ball and Ross (1991) found that the use of all
        illicit drugs, except marijuana, decreased markedly in relation to time in treatment. These three cohorts
        had been in treatment 6 months, 4.5 years, or more than 4.5 years.
        In the Treatment Outcome Perspective Study (TOPS), 90 percent of methadone maintenance treatment
        patients who reported drug use at intake reported a reduction in use during the first 3 months of treatment.
        For 80 percent, this reduction is large. In the year before treatment, less than 10 percent of methadone
        maintenance treatment patients were minimal drug users. During treatment, more than 50 percent of the
        patients were minimal drug users. During the 3 to 5 years after discharge, less than 32.5 percent were
        minimal drug users (Hubbard, Marsden, Rachal, et al., 1989).
        In the National Treatment Outcome Research Study (NTORS), of 333 patients receiving methadone
        maintenance in the United Kingdom, overall declines were seen in the use of heroin, barbiturates,
        amphetamines, cocaine, and crack cocaine among patients receiving methadone maintenance. Alcohol
        use, however, did not change over time (Gossop, Marsden, Stewart, et al., 2000).
        In another evaluation of 513 heroin users in methadone treatment in TOPS, a decline was observed in the
        use of cocaine, amphetamines, illegal methadone, tranquilizers, and marijuana, but not alcohol (Fairbank,
        Dunteman, and Condelli, 1993).

        Yes, I am saying that agencies pay for treatments with a low chance of success. Particularly in Addiction Medicine, treatment becomes politicized. Just look at methadone treatment, which is usually not paid for by private insurance, despite 50 years of studies showing it’s the most effective treatment for opioid addiction. And look at all the money that goes to short detox stays for these patients, who have less than a 10% chance of staying clean for even six months. Yet patients cycle in & out of short-term (less than one week) detoxes.

        My credentials: I graduated from medical school in 1987, became board certified in Internal Medicine & worked in private practice primary care until 2004. In 2001, I got interested in Addiction Medicine, and by 2004 I got certified by the American Society of Addiction Medicine. I happily gave up primary care in favor of full-time addiction medicine in 2004. I’m now certified by the American Board of Addiction Medicine, and I go to conferences frequently to stay current. Last year I went to four conferences, three regional and one national, where I was asked to speak. If I miss one of the big national conferences, I buy access to the recorded sessions to avoid missing anything. I also read three journals in my field.

        However, I’m a relative newcomer to the field, compared to many doctors. But I have had some experience – I’ve worked at 13 different opioid treatment program sites under 5 methadone clinics, some for-profit and some non-profit. I’ve seen the good, bad, and the ugly, and I’ve had to learn much of what I know the hard way.

        But may I never become unteachable. I was serious when I asked if you had published studies about IOP alone and success treating opioid addiction. I’ve looked and looked and can’t find this literature anywhere. it seems the patients tend to drop out.

        Thank you for reading. I appreciate that you take time to read and take time to write comments. I hope you will continue to read.

      • Dear Dr. Burson,
        Thank you for the spirited discussion. I suspect you know we are both committed professionals ever searching for the most beneficial treatment for our patients.
        I come up to my 38th year in addictions treatment this February. I am possibly a bit thin skinned but except your apology.
        I have witnessed much damage done by well meaning MDs and their prescription pads.
        I attempt to have you consider that many different and sometimes conflicting avenues can lead to healthy outcomes.
        I will research outpatient treatment outcomes and report back my findings.
        I do believe that 28 day rehab is preparation for the next overdose and is not at all an appropriate length of stay for opioid addiction.
        Thank you for your efforts and dedication to addressing the No.1 Public Health Problem of our time. The ONDCP and the CDC&P have both categorized overdose deaths as epidemic.
        As a medic on the battlefield I grieve.
        Sincerely,
        Luke

      • Sorry for the typo.
        Meant accept not except.
        Freudian ? No just a typo.
        Luke

  4. Hi! This is an excellent post! I just had genetic testing done and thought of you at the drs office yesterday. Results were very interesting!

    I am currently at 4 subutex and 2 Xanax per day (if needed- I only take if I feel like throat is closing).

    The test showed how my body metabolizes drugs. It was very neat.

    I hope you are doing well! And thank you for this post! And being honest to your patients. I wanted an overnight miracle when getting of hydrocodone. And if I could go back in time, I would have went thru Inpatient detox and been over it all quickly.

    Anyways- I am stable, trying to wean off subutex, and be free- I just don’t know if that will ever happen. But I am taking your advice And dealing with underlying issues before anything else. I didn’t realize I had so many! Haha

    Still have never relapsed on subutex- so from a medical standpoint- it works!

    God bless! Nacole

    Reply

  5. Oh! I just read all the other comments- and want to say I wouldn’t respond to ignorance! Luke apparently has no clue what he is talking about! And I have never even taken methadone.

    The people mixing junk with methadone are addicts Luke! That is not the drs problem who are spending their life trying to save/ help another! People who truly want help- and are sincere about recovery don’t drink on methadone. They follow their drs advice.

    Dr burson has publicly posted a blog about who is NOT a candidate for methadone treatment! Most drs would not do that bc they say everyone is a candidate bc they want MONEY! Those drs happily give it and subutex away like candy bc they want money- and the more the patient comes back- even if it is for life- they make more money! Dr Burson is not like those doctors!

    Those need to be the drs you spend your energy typing to addressing these issues! I pray that you are not a dr! And I pray that you are not trying to become one! Bc you are NOT gonna help addicts with your ugly disposition! Your ugly attitude! And your stupidity!

    As far as her credentials goes- she has spent her adult life researching addiction trying to help people. She has wrote a book that I recommend you read! And she has spoke at conferences. She is a highly admirable and respected dr!

    I am pretty positive your colleagues turned you onto this blog because of your arrogance, and they want you to learn something.

    And before you assume anything, NO, I am not one of her patients and no she has never given me a script of anything. and i am still defending her! she did save my life by simply giving me the time of day and responding back to me! She saved my life and I live in TN! Go figure! That is more than you will ever do!

    If you don’t like her blog, go type your arrogance elsewhere please.
    Good day sir! Nacole from TN

    Reply

  6. Oh! I just read all the other comments- and want to say I wouldn’t respond to ignorance! Luke apparently has no clue what he is talking about! And I have never even taken methadone.

    The people mixing junk with methadone are addicts Luke! That is not the drs problem who are spending their life trying to save/ help another! People who truly want help- and are sincere about recovery don’t drink on methadone. They follow their drs advice.

    Dr burson has publicly posted a blog about who is NOT a candidate for methadone treatment! Most drs would not do that bc they say everyone is a candidate bc they want MONEY! Those drs happily give it and subutex away like candy bc they want money- and the more the patient comes back- even if it is for life- they make more money! Dr Burson is not like those doctors!

    Those need to be the drs you spend your energy typing to addressing these issues! I pray that you are not a dr! And I pray that you are not trying to become one! Bc you are NOT gonna help addicts with your ugly disposition! Your ugly attitude! And your stupidity!

    As far as her credentials goes- she has spent her adult life researching addiction trying to help people. She has wrote a book that I recommend you read! And she has spoke at conferences. She is a highly admirable and respected dr!

    I am pretty positive your colleagues turned you onto this blog because of your arrogance, and they want you to learn something.

    And before you assume anything, NO, I am not one of her patients and no she has never given me a script of anything. and i am still defending her! she did save my life by simply giving me the time of day and responding back to me! She saved my life and I live in TN! Go figure! That is more than you will ever do!

    And medication treatment saved my life bc after failing over and over trying to go cold turkey or even weaning- it didn’t work! I didn’t have the treatment you recommend (6-9 months) as most people do not! I wished inpatient detox would have worked but it fails daily! There isn’t a miracle for quitting a drug or pill overnight like I wished I could have done! However, I have been on subutex a while now, and I have never drank on it, or mixed stuff with it, and have never relapsed – from day one!

    If you don’t like her blog, go type your arrogance elsewhere please.
    Good day sir! Nacole from TN

    Reply

    • Dear Nacole,
      I wish you the best of luck and continued success.
      Sincerely,
      Luke

      Reply

      • Dear Luke- I apologize for my remarks last night! You came across arrogant to me and maybe I was too quick to judge. I apologize sincerely.

        I have witnessed doctors over the past 5 years not having a clue what to do with an addict.
        Even our ER doctors do not do not know what subutex is. I am not exaggerating.

        Where I come from- they won’t even allow me to enter the hospital for medical detox- which is only a 7 day stay in Memphis. And you must be at 16 mg before entering. They refused me! Twice and told me they couldn’t help me. Frustrating.

        Their best solution so far is to switch me to methadone which I refuse to do. Never taken it, never will.

        I have also witnessed many drs ruining people’s lives with a prescription pad. Especially where I am from.

        I respect you for your apology and dr bursons to you. Everyone- drs and addicts must work together to try to save lives.
        I attacked you bc it came across as you were downing dr burson, and her research. I apologize. I am thankful for your work trying to help people with addiction :)

        My apologies! Nacole

  7. I can think of a couple of issues you should consider. In the effort of good spirits.
    Regarding
    #1 back in the days of The State Methadone Treatment Guidelines, SAMHSA thought it was appropriate and I agree. That an ex-methadone patients who might have gotten clean, but now he may be feeling that is going to relapse in illicit drugs SAMHSA indicated that this type of patient could return to methadone even though he/she might not have relapse yet.
    Regarding #2 Seem to me that it would be real hard to determine that someone my have dependency and not addiction. Given that we don’t have a subjective measuring equipment yet to make those distinction. We do not have thermometers, nor MRIs nor blood test that would determine to make this distinction. Clinical judgments, guesses, hunches and educational intuition has shown to be extremely fallible. This research is almost conclusive. Scott Lilienfeld, Science and Pseudoscience in Clinical Psychology, and Dr. W. Garb Studying the clinician (notice not the patient but the clinicians) amongst other authors has shown that clinical judgment made even when the clinician thinks he/she is using traits, criteria and standards.
    4. The opioid addict has the ability to go to a prolonged inpatient residential treatment program for his addiction.
    This is controversial, because some doctors think medication-assisted treatment should be given to everyone because of its success rate compared to abstinence-only treatments.
    It is not secret the residential treatment based on abstinence is a dismal failure. The Internet is full of patients complaining of how treatment has fail them.

    Regarding# 7 and I have to find the studies. Research shows that the longer the patient is in treatment the more likely that they will comply. Of course physical attacks and threats are serious matter. And this also has to do with the communication skills of the clinician that can resolve possibly explosive or escalating events.

    In 8 the only physical disability that methadone may not be call for is brain injuries. and I am not too sure what type of injury located where in the brain etc. And I do not remember the whole shpiel about it.

    That is my three cents and considerations.

    Reply

  8. I do think that you are a clear thinker and give a lot of thought to what you do with patients. I enjoy reading you blog every time I get it in my emails.

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  9. Posted by beth feinsilver cohen on February 8, 2014 at 3:00 pm

    This is a difficult question on both sides, but so many times addiction is fatal, or the results ;can cause long term financial, employment , legal or family problems that can last a life time . I v’e seen so many people caused permanent damage , had they just started on medication right away I think they could have avoided much of it.

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  10. this blog entry brings up an important point I have ALWAYS made about all addiction treatment and the “recovery” movement in the US. For SO long we have told family and friends to let patients “find their bottom” and for far far too many of them their bottom has been death. IMAGINE if we said the same about any other disease? BUT your point about people in professions like doctors and pilots making it AFTER long term treatment proves a more important point about the way addiction is treated-even more important than “different strokes for different folks”!. The fact that success rates for “professionals” in long term treatment are SO much better than the success rates for other people entering rehab PROVE that if a person has a life they love and want to get back to they have a much better chance of success! It’s so sad that with all of our research into addiction it has never occurred to us that letting people fall to their “bottom” might be the very reason the “average joe” (a person without a medical degree or a big house to get home to) has such absyml success rates at any treatment. That the thing we tell family and friends to do to get their loved ones “better” (cut them off or “tough love”) might actually be exactly what makes it nearly impossible for them to succeed! If drugs are all a person has left-if they are told over and over they are useless and every relapse (no matter how brief) is a total failure instead of a minor stumbling block-if a person only has one thing left in the world that gives them warmth, comfort or connection (for many addicts that is their Drug)–how do they muster up the strength to get through treatment and find a better life? I know for me that my career and family are the two things that consistently remind me that staying in MMT is so important. If I didn’t have those things to get “back to” after active addiction-I am not so sure I would have had a reason or the desire to get myself on track. And I see it every time I go to the clinic! I see people that are only there because they need a way to stay well in between getting messed up on other drugs..(.and the truth is I think even that is a necessary step for many people in treatment because it keeps people ALIVE until they find the strength to get BETTER)–but imagine if they believed they could have more? Imagine if they weren’t so ashamed of being an addict or weren’t so beaten by life that they actually believed they could have more than just an existence of one high to the next? In group it NEVER fails to surprise me how SUPRISED my fellow patients are that I work in a hospital and I am on methadone. I almost always have at least one person that says “and they let you?”. Isn’t it really sad that these people believe other people have so much control over what they can and can not do with their lives?

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  11. Nacole-You are absolutely right about most ER doctors not knowing what to do…and more important most of them have NO DESIRE to do it! I am on methadone and having to hear the way doctors, nurses and even clerks speak about the addicts they are supposed to be HELPING- well its disheartening to say the least. I even had one doctor say to me “I am so sick of these addicts flooding the ER with their problems! I wish I didn’t have to treat these people that made THEMSELVES sick”. OH how I wanted to laugh–if he didn’t treat people with some element of “doing it to themselves” to their illness he would no longer have a job! 90% of ER visits are patients who either ate, drank or “stupided” (as in did something REALLY dumb) their way into a disease or injury!

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  12. I have a question regarding Methadone,My is on 95 and is still waking up in withdrawals after 8 months and gradually increasing..He also has ADHD and I am wondering if his metabolism is such it is not holding as long as most..My question is do we keep going up…that seems to be the route his clinic is taking..Just concerned it will be a never-ending increase with the same outcome as his body’s adjust to the new increase..Thank-you for your blog,it has given me alot of info and silenced alot of fears I had when he first entered the program 5 years ago( he is on & off due to relapses and being kicked out).

    Reply

    • In my experience, 95mg is not a high dose. Most patients stabilize somewhere between 80-120mg, but there is a vast difference in the speed at which patients metabolize methadone. Some patients feel fine at 30mg, while others need to go into the 200’s or more.
      Patients don’t develop tolerance to the anti-withdrawal effects of methdaone, so once your son gets to a dose that prevents withdrawal, he likely won’t need any major dose adjustments unless he has dramatic life changes like changing work schedule, medical problems, or new medications that speed methadone metabolism.
      Some patients do have a “more is better” mindset entering treatment, because that’s what the disease of addiction tells the brain. Therefore it’s the program physician’s job to meet with your son and describe what’s reasonable to expect from this medication and what is not. Some patients get a little extra energy for the first two to three days after a dose increase, even if they no longer have any withdrawal. That energy always goes away, so repeated dose increases don’t help…unless there’s opioid withdrawal. Granted, it can be tricky to figure out at times.
      Hopefully your son will allow you to be part of his recovery, and allow you to talk to his counselor and/or program physician. There’s evidence of better patient outcomes when family get involved too.
      Thanks for reading.

      Reply

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