Archive for the ‘methadone’ Category

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.

News From the World of Addiction Medicine Research

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The latest issue of the Journal of Addiction Medicine, Vol. 7 (2) March/April 2013 had several interesting articles relating to opioid addiction and its treatment. Here’s my quick summary and thoughts on one of them, “Promethazine Misuse among Methadone Maintenance Patients and Community-Based Injection Drug Users,” by Brad Shapiro et al, pp. 96-1001.

This study attempted to get an idea of the prevalence of promethazine (better known under its brand name Phenergan) use in opioid addicts both in and out of treatment.

I was interested in this article because I’ve had methadone patients misuse promethazine. Most of these patients say that Phenergan gives them sedation with methadone, but most say it’s not a true euphoria, so I’m puzzled as to why they mix the two. Since promethazine can be sedating in many people, obviously I worry about overdose deaths when it’s mixed with methadone.

The authors of this study tested for promethazine in the patients enrolled in a county hospital methadone clinic in San Francisco. Twenty-six percent were positive for promethazine and only 15% had a prescription for this medication. Also, promethazine use was associated with benzodiazepine use.

The authors then recruited two hundred intravenous drug users, and discovered that only 139 were opioid addicts. Of those 139 addicts, seventeen percent reported promethazine use in the past month. However, of the addicts who had been on methadone in the past, twenty-four percent reported promethazine use in the past month.

What does this study tell us? The authors’ conclusion was that promethazine needs to be investigated further as a drug of abuse in opioid addicts.

Well, yeah.

My clinical experience gave me some thoughts about the study. For one thing, pregnant addicts were excluded. But in my experience, pregnant patients are the ones most likely to be prescribed Phenergan because of morning sickness during pregnancy. And this study doesn’t tell us much about the overdose risk when methadone and Phenergan are combined. Early in their article, they do provide some data: In Kentucky, over 14% of decedents from methadone toxicity overdose deaths also had promethazine present in their system. In Seattle, 2.5% of fatal overdoses had promethazine present.

Promethazine, along with many other medications, prolongs the QT interval just like methadone does. I haven’t seen any studies of methadone patients comparing QT intervals before and after promethazine, which may be helpful to further assess risk.

Important Factors for Successful Opioid Treatment Centers: Staff Experience

As discussed in my last blog entry, some opioid treatment centers (previously called methadone clinics) are better than others. Last time I blogged about the importance of communication between staff members. This blog is about the importance of hiring experienced, competent staff.

For an opioid treatment center, the worst counselor to hire is one who doesn’t believe in methadone. This should go without saying, but sometimes clinics hire people who are conflicted about methadone (or Suboxone), and either verbally or non-verbally communicate their uncertainty or negative attitudes about methadone. The effects on patients can be devastating. Fortunately most of these employees don’t remain at opioid treatment programs, either because they must be terminated for the welfare of patients, or because they quit on their own.

Some patients say they’d rather have a counselor who has personal experience with addiction and recovery, because he understands addiction at a deep level. Such a counselor can be valuable, but it’s not enough. A counselor also needs knowledge of counseling techniques and the skill to apply them appropriately. If recovery from addiction is the only attribute of your counselor, why pay for treatment? You can get the same thing for free at any 12-step meeting.

The factor most correlated with patient success in counseling is the relationship with their counselor. A warm and accepting, non-judgmental attitude is most successful. In short, compassion is important. While it’s true that another recovering addict can understand the pain of still-suffering addicts, non-addicts can be just as compassionate, and may have fewer preconceptions about what recovery must be.

The Substance Abuse and Mental Health Services Administration, often called SAMHSA (SAM-sah) for short, produces many publications to serve as guidelines for substance abuse and mental health treatment facilities. They’ve published “Technical Assistance Publication Series, Number 21: Addiction Counseling Competencies.” This document outlines all the necessary skills and knowledge that an addictions counselor should have to work in any drug addiction treatment program.

Counselors must understand addiction. They need to have education about drugs of abuse and how they affect the body and how withdrawal from various drugs affects the body. Counselors should know about all forms of drug addiction treatment, and know which treatment is most appropriate for their client. They should be able to apply helping strategies to best meet the needs of their clients.

Counselors need to be professionals, and conduct themselves in a capable and courteous way. One of my peeves is to hear clinic personnel refer to a urine drug screen positive for drugs as a “dirty” screen. Language matters. Counselors need to have a certain level of self-awareness with good boundaries. This prevents them from being too involved with their clients, or too distant from their clients. They need to follow the profession’s ethical standards. They need to be aware of the need for continued education and be open-minded to new information. This is a rapidly changing field, and counselors shouldn’t continue to work with dated knowledge from the 1980’s.

Once a clinic gets good counselors, they need to keep them. Patients get discouraged when they’re assigned a new counselor every few months. At one clinic where I worked several years ago, a patient told me he’d had six counselors over fifteen months. That’s not OK. Patients get tired of discussing their issues with one person and form a counseling relationship, only to have to start anew a few months later. Staff turnover discourages patients.

Of course, some turnover can’t be avoided in our mobile society, where people switch jobs frequently. But clinic owners need to try to keep good counselors (and nurses and doctors) and retain them to benefit the patients. Clinic owners should be willing to pay staff well, and provide adequate benefits.

Opioid treatment programs need to hire good nurses and doctors, too, with experience and training treating patients with addiction. Doctors should be certified in Addiction Medicine either through the American Board of Addiction Medicine, or through the American Academy of Addiction Psychiatry. And they need to go to continuing education meetings to stay current, since the field of Addiction Medicine changes so rapidly with new research and results.

When I started work at my first methadone clinic, I didn’t know much more than to start the dose low and increase slowly. In retrospect, I should have had more training. If a new doctor has no prior experience working in opioid treatment programs, I’d favor a training course similar to the  course available for doctors who want to prescribe Suboxone.

I love my present opioid treatment program, Stepping Stone of Boone. We’re a new clinic, and relatively small at around 130 patients. We opened in April of 2010, and have had no staff turnover. That’s right – none. All the staff that pioneered the clinic is still there, and all of the new people hired over the last 18 months have stayed. That’s a sign of a good clinic.

It’s a fun place to work because each of us loves what we do, and we believe in what we do. We enjoy not only our patients but also the other staff members. We feel like we are helping people.

My next blog entry will be about the importance of evidence-based dosing of methadone.

Qualities of Good Opioid Treatment Programs

Not all opioid treatment programs are created equal, meaning some are better than others. Over the years, studies have shown which clinic factors are associated with better patient outcomes. Over the next week or so, my blog postings will elaborate on each of the following factors:

  • Good communication between medical, counseling, and administration portions of the clinic
  • Experienced staff with adequate training and low turn-over
  • Low patient to counselor ratios
  • Program follows evidence-based guidelines for dosing
  • Opioid treatment program provide more care than just methadone treatment (also provide primary care, vocational rehabilitation, etc)

Today I’ll blog about communication between staff members. Communication is a good quality in any business, allowing it to run more smoothly. But it’s even more important in healthcare, where patients’ lives and well-being are affected.

In opioid treatment programs, communication happens in many ways, but case staffing is the most formal and efficient. Case staffing is when multiple members of the treatment team gather in one place, usually at a set time, to discuss what’s going on with patients. The treatment team usually includes all of the counselors, the nurses, the doctor, and the program manager. Besides communicating information about patients, case staffing also helps generate creative solutions to problems, and checks for negative emotions among staff. This can also be a forum where concerns about clinic protocols can be raised by staff.

At the program where I work, once or twice per week, after we finish seeing the day’s patients, the nurses, the counselors, nurses, program director and program manager sit in our lobby and discuss patients. First we talk about the new admissions. I tell the staff of any medical concerns I found on my intake assessment. For example, if a patient was found to have an enlarged liver on my exam, I ask the counselor to follow up with the patient later in the week to make sure the patient makes an appointment with his primary care doctor. The counselors raise concerns about new patients. Perhaps one of the counselors noticed symptoms of depression and we decide I should check that patient again the next week, when opioid withdrawal isn’t as severe.

Then we discuss established patients, and try to problem-solve. For example, maybe a patient needs to travel out of town for work, and there’s no opioid treatment program nearby where he can guest dose. We talk about the patient’s progress and whether it’s appropriate to ask the state methadone authority for extra take-home doses. We have some leeway to decide about Sunday and holiday take home doses, and discuss who is ready for these take homes.

Counselors may ask about how to approach ongoing drug use. The approach is different for different types of drugs. If a patient has had repeated relapses to opioids, maybe the methadone dose needs to be increased. If benzos are a problem, we must discuss if it’s safe to continue to dose that patient with methadone. For marijuana and cocaine, more intense counseling is indicated, and we discuss the best approaches.

Case staffing also helps us watch each other for negative attitudes. Patients with addiction sometimes behave badly. In active addiction, some addicts have had to lie and deceive to survive, and these tendencies don’t disappear overnight. The whole staff of an opioid treatment program needs to watch each other for negative or pessimistic attitudes developing toward patients.

For example, recently I was in a case staffing where we were talking about the repeated relapses of a patient. I made a comment which was more negative than the situation warranted, and this patient’s counselor appropriately challenged my comment. I’m no different than any other human and can take a skeptical view of a patient when it’s not reasonable. This counselor made me re-consider my opinion, and she was right to do so.

We talk about clinic policies that may need to be changed. For example, when patients can’t pay for treatment, how long do I have to taper their methadone dose? I’ve worked in clinics where if you didn’t have money for that day’s dose, you didn’t get a dose. They had no policy in place to allow a taper. I’ve worked in clinics where the dose was tapered over 4 days. At my present clinic, the dose is tapered over ten days. That’s still too short, and I’d prefer to keep everybody in treatment for free, but that’s not possible. The program would fold. I’ve had the unpleasant experience of working for a methadone program that closed because it ran out of money to operate. So it’s important to include the clinic administrators in some aspects of case staffing.

The best part of case staffing is talking about patient successes. Counselors talk about patients who are participating in counseling, who’ve had negative drug screens, and qualify for take home levels. Unless any staff member has concerns, I sign a form to make it official. We talk about patients who have recently gone through difficult situations without using drugs. We even have an unofficial “patient of the week,” a term for the patient who has worked hard on recovery and had a recent success. Sometimes it’s a patient who got a job promotion. Sometimes it’s a patient who has started going to 12-step meetings. Sometimes it’s a patient who has a negative drug screen for marijuana because he’s stopped smoking pot for the first time in his entire adult life.

Talking about this good stuff is so important for staff. We get to feel like we are at least some small part of the positive changes happening in the lives of our patients. Fortunately, there’s much to celebrate at every case staffing. As I’ve said before, I never saw the kind of positive changes when I worked in primary care that I see working in addiction medicine.

 

Dosing Methadone for Pain versus Addiction

Using methadone for pain is different from using methadone for addiction.

It’s illegal in the United States for a doctor to prescribe methadone for the purposes of treating addiction, unless she is working at an appropriately licensed Opioid Treatment Center. Some doctors don’t know this, and have had grumpy DEA agents pay them a visit. However, it is legal for a doctor to prescribe methadone for pain, as long as she has an appropriate DEA license.

Methadone is prescribed differently when treating pain than when treating addiction. This is because each dose of methadone has an analgesic (anti-pain) effect of about six hours. However, methadone’s opioid blocking effect lasts for twenty-four hours or more. This is why methadone for pain should be dosed multiple times per day, but methadone for addiction can be given once per day.

The dose of methadone often varies, too, depending on the disease being treated. Doses of methadone 10 to 20mg, dosed three to four times per day, are adequate to treat pain for many patients. When treating addiction, studies have shown that patients do better when the doses are high enough to block other opioids. Usually, this occurs at doses 80 – 120mg per day, given as one dose. The patient doesn’t become sleepy or sedated at this dose because the dose is raised gradually, allowing time for tolerance to build to the sedating effect.

Some patients prefer to stay at a low methadone dose, so they can still feel intoxication from illicit opioids like heroin or oxycodone. For example, one patient told me he liked keeping his dose around 60mg, which was high enough to stave off the worst of his withdrawal symptoms. But it was also low enough to allow him to feel high from an injection of heroin in the evenings. He resisted going up on his dose as recommended by his treatment team.

Doctors have to be very careful prescribing methadone for pain. The very characteristic of the drug that makes it effective to treat addiction, its long duration of action, also makes it dangerous to prescribe. Too many patients, experimenting with methadone for the purpose of getting high, die of a drug overdose. Tolerance to the euphoric effect of methadone develops more quickly than the tolerance to the sedative effects. People consume a fatal dose before feeling high.

Over the last decade, the incidence of overdose deaths from methadone rose sharply. Most of these deaths were from people taking methadone pills, dispensed from local pharmacies, and prescribed by doctors who were treating patients for pain. Along the way, many milligrams were diverted to the black market, with disastrous results. Some methadone was diverted from opioid treatment centers, but appears to be a fraction of the total.

Given the overdose potential of methadone, it should be used cautiously when prescribed by physicians for pain. Soon, doctors may be required to take a training course before they can prescribe the long-acting opioids. This training will educate doctors on how to recognize if a patient is developing the complication of addiction, and to identify evidence of drug diversion.

Best Treatments for Addicts who Snort or Inject Suboxone

Suboxone misuse is much more common than I realized, as I’ve learned from people who write comments to this blog. These opioid addicts have described how they snort, inject, and even anally insert the Suboxone that’s meant to treat their addiction.

Not every addict can be treated with Suboxone from a doctor’s office. For some patients, the addiction is too strong, and they are unable to use the Suboxone as instructed. If a patient is injecting or snorting the medication meant to help them, they aren’t in recovery. These addicts need to be referred for another form of treatment. They aren’t being helped with Suboxone, except that perhaps it’s a little safer then other abused opioids, since at least there’s a ceiling on its opioid effects.

 What are the best options for these addicts? 

Most aren’t willing to go to inpatient detox followed by prolonged (one to six months) residential drug rehabilitation. It’s costly, and no one likes to be away from home for that long. However, this form of treatment can be life saving and gives the best chance of drug-free recovery.

Or they could enroll in an opioid treatment program, called OTP for short. In the past these facilities were called methadone clinics, because that was the only medication offered, but now many clinics also use buprenorphine. I’m glad to see this trend. For many patients, buprenorphine is a better drug. Patients tend to feel less medicated, and are less likely to feel any euphoria from buprenorphine. And the clinic gives patients more structure than I can from my office.

At OTP (opioid treatment programs) the patients are seen every day. Most clinics are open at least six or seven days per week. That way, patients can be given an observed dose each day. They won’t be able to misuse their medication, since a nurse places the tablet or film under the tongue, with buprenorphine. Methadone, dispensed as a red liquid, is swallowed each day in the presence of the nurse. Diversion to another person certainly isn’t impossible, but it’s much less likely to occur.

 So to all of the addicts now using Suboxone in unorthodox ways, snorting, injecting, and other ways, tell your doctor what you are doing. You can get your addiction treated by going to a clinic each day. Counseling is built into the opioid treatment program system. Patients there must see their counselors, and many clinics also make group sessions mandatory.

 I’ve become gradually more selective about who I’m willing to treat with Suboxone in my office. I’m more vigilant about medication misuse, since this blog taught me that it happens much more frequently than I previously thought. I now believe that only very stable opioid addicts should be treated in an office setting. Older addicts with jobs, families, and no other addictions appear to do the best in this type of treatment. From now on, if I have openings for new patients, I’m going to screen more rigorously. Many addicts have an addiction that’s too severe to treat with office-based therapy.

Tramadol, AKA Ultram, Ultracet

I just returned from the American Society of Addiction Medicine’s spring conference, held in Washington, D.C. I go to at least one of their meetings every year, to stay current with the latest research and developments in Addiction Medicine. It was impossible to attend all of the sessions, since four or five meetings are often conducted at the same time. This makes it the intellectual equivalent of a three ring circus. I think I learned some new stuff, and will share some of this in my blog over the coming weeks.

The first day, I went to a day-long course called “Pain and Addiction: Common Threads.” I think this is the fourth time I’ve attended that particular seminar over the last eight years. I hear something new every year.

 It’s striking how much this meeting has changed. The first year I went was 2005. At that time, pain medicine specialists still debated with the addiction medicine specialists about the risk of addiction in patients who were prescribed opioids long-term for chronic non-cancer pain. By 2010, I didn’t hear any debates about the risk of addiction. I heard lectures about how to manage chronic pain without opioids, and about the risk of hyperalgesia in patients on long-term opioids. Hyperalgesia is an increased sensitivity to pain, sometimes seen in patients prescribed opioids for months or years. The human body accommodates to the presence of these prescribed opioids, which adjusts the pain threshold, making a patient on opioids paradoxically more sensitive to pain.

This year, the Pain and Addiction conference had lectures on several interesting topics, but one that captured my interest was about the not-so-safe “safe” medications. Included were carisoprodol (Soma), zolpidem (Ambien), butalbital (found in Fioricet and Fiorinal), and tramadol (Ultram). These are all medications that many doctors think are safe for addicts, but really aren’t all that safe.

I’ve seen many patients develop problems with tramadol, so the rest of this blog is about this medication.

Tramadol is a messy drug. It’s a pain reliever that has actions on several types of brain receptors: the mu opioid, serotonin, norepinephrine, NMDA, and other receptors. Because it stimulates the mu opioid receptors, it can cause feelings of pleasure as well as pain relief. Tramadol is far less active at the mu opioid receptors than its metabolite, and it takes time for the tramadol to be metabolized in the liver to its first metabolite. Because of this delay, some experts thought it wouldn’t appeal to addicts, who prefer an immediate high. Overall this is probably true, and tramadol has a much lower rate of addiction than other opioids, but it still causes addiction in some patients.

Some of tramadol’s pain relieving properties may also be produced by its actions on serotonin and norepinephrine receptors, since tramadol’s pain relieving capability is only partially reversed by a pure opioid antagonist like naloxone.

When this medication was first released, it wasn’t a controlled substance. That is, the DEA didn’t control it strictly like medications that can cause addiction. Now, it’s a Schedule IV drug, thought to have benefit but also some risk of addiction, though lower than that of hydrocodone, for example.

Tramadol is usually dosed in 50mg pills, one or two every six hours, giving the maximum dose of 400mg per day. Recreational use of this medication (to get high) is dangerous, since it causes seizures at doses higher than 400mg. In susceptible patients, it can even cause seizures at lower prescribed doses.

I’ve seen patients in tramadol withdrawal who were so sick it frightened me. This drug can produce a severe withdrawal. When it’s stopped suddenly, patients have opioid withdrawal symptoms like sweating, nausea, diarrhea, high blood pressure and heart rate, and severe muscle and joint pains. The sickest patient I’ve ever seen in opioid withdrawal had been using only tramadol, in doses of around 600mg per day. She had fever to 103 degrees, and dehydration from the diarrhea and vomiting. That patient needed hospitalization.

Besides the opioid-withdrawal symptoms, some of these patients also have withdrawal symptoms similar to those seen when certain serotonin-affecting antidepressants, like Paxil and Celexa, are stopped suddenly. They can have fairly severe anxiety, depression, mood swings, and restlessness. Many times they have weird sensory experiences, often called “brain zaps,” or the sensation of electric shocks throughout the body. They can have seizures during this withdrawal.

If the patient had only physical dependency and no addiction, the dose of tramadol can usually be tapered slowly over a few weeks to months, as an outpatient. But if the patient has not only physical dependency but also the disease of addiction, the obsession and craving for the medication will usually prevent a successful outpatient taper, unless a dependable non-addict holds the pill bottle, and dispenses it as prescribed.

Traditional treatment for tramadol addiction starts with detoxification. As above, that can rarely be done as an outpatient, so medical inpatient detoxification admissions for five to seven days can be helpful. However, since tramadol acts so much like an opioid, patients ready to leave detox probably need to go on to an inpatient residential treatment center for at least thirty days.  Intensive outpatient treatment probably isn’t enough support for these addicts. But that’s only my opinion, since I haven’t found any studies describing success rates with tramadol addicts.

Opioid maintenance medications like methadone and buprenorphine do stop the opioid-type withdrawal symptoms from tramadol, and patients probably benefit from medication-assisted therapy just like any other opioid addicts. Using these medications, they can be successfully treated as outpatients. However, as above, I can’t find any long-term studies of tramadol addicts on replacement medications. One of the addictionologists with whom I work doesn’t think it’s wise to put an addict who is addicted only to tramadol on methadone, given the lack of data. However, usually these addicts are using other opioids too, and physically addicted to them as well as tramadol.

Often, methadone patients at the opioid treatment centers where I work are given tramadol by their primary care doctors who think it’s a low risk medication for opioid addicts. It probably is lower in its risk for abuse, but it can cause withdrawal in patients on stable, blocking doses of methadone. (1)

Tramadol is a synthetic, pared-down version of codeine. Interestingly, a structurally similar medication, tapentadol, has just been released, and is now being sold under the brand name Nucynta. That medication is a schedule II drug, presumably because of a higher abuse potential than we’ve seen with tramadol. Tapentadol stimulates opioid mu receptors, and also acts as a norepinephrine re-uptake inhibitor, like some antidepressants. It will be interesting to follow abuse and addiction patterns with this medication.

The bottom line is this: if you are in recovery from addiction (alcohol or drugs) this medication should be used with caution. Let your doctor know that you’re in recovery from addiction. If you must take a potentially addicting medication, talk to your sponsor and your support network. Go to extra meetings. Let a dependable non-addict hold the pill bottle and dispense as prescribed. If you have to take the medication for more than a few weeks, have your doctor taper your dose instead of stopping suddenly.

I’ll have upcoming blog entries concerning Soma, Ambien, and Fioricet.

  1. Leavitt, MA, PhD, “Methadone-Drug Interactions,” Pain Treatment Topics, Addiction Treatment Forum, January 2006

Methadone Dosing, Part 1

“Doc, I need a dose increase. The last time I went up 5mg, I felt it for a few days, but now I don’t feel it anymore.”

I’ve worked in opioid treatment centers for around ten years, and I often hear this kind of statement. It’s worrisome, because it doesn’t fit with the pharmacokinetics of methadone. I have to ask the patient exactly what he means when he says he “feels it.” Does he mean he feels a bit of enjoyable euphoria? Or does he mean he feels relief of nighttime physical withdrawal symptoms? If he means the latter, I’d expect those symptoms to be improving on the fourth or fifth day, because of the long half-life of methadone.

 We see from the graph of the steady state of methadone that it takes at least four or five days to see the full effect from a dose change. However, a person on methadone sometimes does feel a bit of a buzz, or euphoria, for the first few days after a dose increase. That euphoria, which some people experience as increased energy, always wears off, no matter how high we take the dose. In fact, that’s one reason why we use methadone. Patients at a maintenance dose don’t feel high. 

Some patients exaggerate symptoms, or say what they think is expected, because they’re anxious they’ll never get enough methadone to help them feel physically back to normal. I think it’s important to reassure patients that we really want to give them enough methadone to feel stable. And we also have to tell them that they need to tell us the truth about how they are feeling, because they may be chasing a feeling from methadone that’s not going to last, no matter how high the dose.

 Many patients don’t know what normal feels like. It’s part of my job to educate them that on the ideal dose of methadone, you should feel the same all day. Ideally, they feel the same before dosing as after dosing: no withdrawal symptoms, and no euphoria or sedation.

Medical Community Stigma Against Methadone

Educating Doctors

Not many physicians in our communities are familiar with what methadone clinics do or how they work. Some physicians criticize their patients on methadone, even if the patients are doing well and are in stable recovery. Some physicians are unyielding in their opposition to methadone treatment, even though they know little about it.

When given an opportunity, I try gently to educate these doctors, and offer them information. Sometimes I’m pleasantly surprised at the desire of other doctors to learn more about the treatment of opioid addiction with methadone. Sometimes, I’m not surprised at their resistance.

 I’ve felt frustrated by these doctors, but I need to remember that before I knew much about methadone, I opposed it too. Back then, it just seemed wrong to give an addict methadone. I didn’t have any reason for my belief, not being familiar with actual data.  I try to remember my past actions and beliefs, and have compassion for other doctors. They probably know as little about methadone as I did, before I worked at an opioid treatment center.

            A doctor does not work at methadone clinics because of the professional prestige. If subspecialty prestige were a totem pole, and cardiovascular surgeons and neurosurgeons were at the top, then addiction medicine doctors would be the part of the totem pole that is underground.

Our colleagues know little about what we do, and tend to think of us as on the fringes of “legitimate” medicine, even though, as I’ve said before in this blog, we have more evidence-based data to support what we do than perhaps any other specialty.

Occasionally, I encounter a physician who refuses to take care of a patient who is prescribed methadone by a treatment center. One doctor, a bariatric (weight loss) surgeon, told a patient who was doing well on methadone that she would have to taper off of methadone before he would schedule her weight loss surgery. The patient asked me why she needed to be off methadone. Since I knew of no good reason, I called the surgeon. I tried to advocate for my patient, and explain that methadone patients can, and do, undergo all sorts of surgeries. I explained the usual method of maintaining the same methadone dose while in the hospital, and giving short-acting opioids for management of pain after surgery, but this surgeon didn’t relent. He didn’t give me a reason for his decision, and since this was elective surgery, he had the right to refuse to do the operation.

The patient, eager to have this surgery, tapered off methadone. It took months, and I don’t know what happened to her after surgery. I do know she was at high risk for a relapse back into active addiction, particularly since she would need prescription opioids during the post-operative period. I hope she did well.

Recently, a prescription pain pill addict, also being treated for an anxiety disorder, entered treatment at the methadone treatment center where I presently work. She was seeing a psychiatrist who, in addition to counseling this patient, was prescribing alprazolam (Xanax) for anxiety. The patient hadn’t told the psychiatrist about the pain pill addiction, due to shame and embarrassment. When she started methadone, I asked her permission to contact her psychiatrist, so that we could coordinate our treatments. When I spoke to this psychiatrist, she said this patient would be kicked out of her practice. The psychiatrist said, “Going on methadone goes against what I’ve been trying to do for her.” I pressed about what she meant by this remarkable statement, but she wouldn’t, or maybe couldn’t, elaborate. Because this patient entered treatment for opioid addiction, she had to find a new psychiatrist.

These are extreme examples. Most doctors are hesitant to prescribe anything for a patient on methadone, but are grateful if I call them with information, and offer to work with them. After becoming more informed, many doctors are willing to work with, and not against, the opioid treatment center helping their patient.

The Story of a Recovering Addict

Following is an interview with a successfully recovering opioid addict. He received treatment at methadone clinics off and on for years, and finally achieved medication-free recovery after going to an inpatient treatment program for 42 days. Later, he began to work in the field of addiction treatment as a methadone counselor. He was promoted multiple times over the years to his present position as director of the narcotic treatment program at his clinic. This is his perspective about his own experience and what he’s seen with methadone treatment.

JB: Can you tell me your title at the opioid treatment clinic where you work?

KS: Director of Narcotic Treatment, which is our opioid treatment program. [He supervises counselors working at multiple clinic sites, with a total census of around thirty-four hundred methadone patients]

JB: Can you please tell me about your own opioid addiction, and how you got into recovery, including what kind of substances you may have used, what kind of treatments, and your experiences with them?

KS: I started out using pain killers, mostly Percodan tablets, back in the late 70’s, which lead me to using heroin. Heroin wasn’t easy to get [where I lived], so I started using Dilaudids [a name brand of the drug oxymorphone]. I started using Dilaudid on a regular basis in the county I lived in. That was the primary drug I used for quite a few years.

[My] first experience with methadone treatment started in 1978, with a brief episode of treatment, a matter of a month or so, with no success. Pretty much during the 1980’s, I was on and off methadone programs with little or no success, because I refused to participate in group or individual sessions. At the time, there was very limited counseling going on [at methadone clinics]. If there was a problem, you saw your counselor, and that didn’t happen a whole lot. Patients were simply trying to get more methadone. At that point, the methadone dosages were very low. I think the average dose back then was somewhere between forty and fifty milligrams. And we [patients on methadone] didn’t know that. We didn’t know that. We just found out through….

JB: You didn’t know what dose you were taking?

KS: Oh, no. We didn’t know what dose we were taking, for a number of years. As a matter of fact, that didn’t change until right before 2001.

JB: Wow

KS: Yeah.

JB: Could the patient find out if they wanted to? [the dose they were taking]

KS: We were blind dosed then. That didn’t change until just before 2001.

JB: Was that unusual for methadone clinics to do?

KS: To my knowledge, I think we [the clinic where he now works, and previously was a patient] were one of the last ones to keep doing that. It was just something we had done over the years and never changed it. [The patients] didn’t know what their dose was.

Through the 1980’s, I was on and off methadone programs, sometimes for a few years at a time, and sometimes had some success. The biggest benefit I had from taking methadone and being on the program was that I was able to work. I held a job the entire time, and I wasn’t doing anything criminal.  It served the purpose it was supposed to serve there, because I had to work, and I was able to function fairly normally. But I never moved into actual recovery, and still used some opiates from time to time. So that was pretty much the 80’s. Two good things happened in the 80’s. In 1981 my son was born, and in 1989, I got clean.

JB: Big things.

KS: Two monumental things in my life. So, I went through that period of time I had talked about, when I started using opiates, in about 1974. Then I started getting on the methadone programs, on and off, [starting] from ’78, but I continued to use. I was using Dilaudids on a daily basis for a number of years. When I got on the methadone program, I would curtail that, but always wanted to go back to Dilaudid. That [Dilaudid] became my drug of choice.

I was on the methadone program in 1989, and having some problems with alcohol. Prior to getting on the program, I was told, “We’re not going to allow you on the program, unless you go on Antabuse.” So I did that and I was successful at stopping drinking, and had some success with methadone. I decided I wanted off the methadone, started detoxing off, and had a series of positive drug screens for a variety of opiates: morphine, Dilaudid, and several different things I had access to. The methadone center said, “We’re going to make a recommendation that you enter residential treatment.” And I said, “Sounds great to me, I’ll do that in a couple months.” And they said, “No. We’re going to make a recommendation you do that… pretty quickly.”

And that’s what happened. I said, “I don’t think I can do this. I’ve got some things to do.” And I remember it like it was yesterday. The counselor got up and walked out of the room and he left me sitting there by myself. Then he walked back in, said, “We’ve got you a bed.” And that’s what lead me to [inpatient treatment].

So I went to forty-two days of residential treatment, and actually entered that program ready to quit using and get into recovery. And from that point on, recovery has been the most important thing in my life….family, of course…but I’ve pursued recovery since May 3, 1989. I followed all the suggestions. [I’m] still really involved with 12- step meetings, and still really involved with some of the same things I did when I first came in [to recovery]. Obviously, I don’t go to as many meetings, but still go to meetings on a regular basis

JB: Do you have any regrets about either type of treatment? The forty-two day inpatient or the methadone?

KS: I do believe that in my case, I needed to be taken away from my environment, simply because of the people I was associated with. That’s not the case for everyone. In my case, I needed to be away from my environment. So the detoxing from the methadone and going into a residential program, that’s what worked for me. Obviously, people can do that other ways. But I still had people in my life that were negative influences.

JB: If you had an opioid addict who presented for treatment for the first time, what would you recommend? If money were no object?

KS: I’d recommend that individual seek inpatient treatment. Now, if they had an extended history of opiate dependency, then that person’s success rate in residential treatment is obviously going to be limited….and…it would just depend on the individual. Methadone treatment might be the way for them to go. I know that’s kind of teetering on the fence. I’m going to be somewhat….I’m going to hold on to how powerful residential treatment was for me. But I had failed at methadone treatment. And, there again, it was a different time, the methadone doses weren’t enough at the time.

JB: Did you feel normal on your dose of methadone or did you [still] feel withdrawal?

KS: I was feeling normal, however, I could still feel drug use [other opioids].

JB: So it wasn’t a blocking dose?

It was not a blocking dose. You knew if you got medicated at 7:00 am, at 5:00 pm you could fairly well feel somewhat of a rush and feel the effects of [other opioids].

JB: How did you get started working in the field of addiction treatment?

KS: I came out of treatment, worked for a family business for a couple of years, and always, from day one, I thought, “What a fascinating thing….if I could somehow do this…to get into that line of work [meaning addiction counseling].

 I started, after two years, as an evening counselor at a residential treatment program, and saw that I really wanted to do that. There was an avenue for non-degreed people to come in to a counselor position. You didn’t have to have a degree in substance abuse or anything like that, so I pursued that, and followed the certification process. I didn’t work in residential treatment but nine months, and then moved to methadone counseling. From that point on, I had found what I wanted to do. And I’ve been offered a promotion at the treatment center to another department when I was over the methadone program, and turned it down to stay with that population [meaning opioid addicts in treatment on methadone].

JB: So you obviously enjoy it.

KS: Oh yeah.

JB: What did you like about it?

KS: I think my ability to relate to that population, without having any thought or putting any real effort…I don’t have to think about it. I know I can talk to that population, and I know I can make them feel normal, by just holding a conversation with them….it might not be about drug use. It might not be about anything pertaining to the treatment episode, but I feel like…that I know exactly where they’re coming from, and I can give them some hope that they don’t have to keep living that way. Just an identification with that population.

JB: That’s a precious gift.

KS: I agree.

JB: Do you believe that your background in addiction helps you when you talk to patients?

KS: I do. I believe wholeheartedly that you can’t teach that. I’ve had some people work for me who had a graduate degree, have never personally had an incidence of opioid addiction or any addiction in their family, and they’re absolutely fantastic clinicians. And you know they’re in that line of work for a reason. So [personal experience with addiction] does not need to be a criterion; in my case, it helps. I find it fascinating to watch someone work who has no self-history of addiction. They can be very effective.

JB: What are the biggest challenges you face now at your work?

KS: That would be…documentation. [The demand for] documentation in this field has really overcome the interpersonal relationship. I can’t help but think as time goes on, that’s going to continue. We don’t have twenty or thirty minutes to sit down with a client, and get into one issue after another, or whatever [the client] may have on their plate. And in opioid treatment, a lot of times it’s brief therapy. They [patients] don’t want to talk to you for twenty or thirty minutes. But you don’t have time to do that, because of the documentation. [The counselor has] three people waiting in the lobby, and you’re kind of selling that person short.

The documentation standards continue to rise, and in methadone treatment, I don’t know how that can go hand in hand with a fifty to one case load. Whereas, someone else might have the same documentation required in the mental health field, but they might have sixteen people they’re seeing.

JB: So you’re saying that the state and federal regulations about documentation actually interfere with the amount of counseling the patients get?

KS: Right. Right.

JB: That’s sad.

The clinic where you work has eight different sites. Can you tell me about what sort of interactions you’ve had with the community leaders, local police, and medical community?

KS: Overall, with any opioid treatment program [methadone clinic], there’s going to be a negative stereotype associated with it in the community, as you well know. Local law enforcement has a bias [against] the [methadone] program. What we’ve found is, any interaction we have with them, and the better understanding that they have [of what we do], the better. And I believe we can make a difference in what law enforcement, and other areas of the community [think about methadone programs].  It’s going to have to happen one person at a time.

An example of that would be when I got a call, a couple of weeks ago, to one of the clinics at ten o’clock at night. An alarm is going off. So I meet the police out there, and we go in, make sure nobody’s in the building. I’m trying to give him some information about it [the methadone program].

He says, “Is it true they come in every day and ya’ll shoot ‘em up?” (laughter) So he thinks that’s what happens.

            So, I educated him on what we do and followed that up with, “Why don’t you stop by and get coffee any time you want to and we’ll give you information.” They were very receptive to that. That’s how you’ve got to approach it. Be willing to talk to people and give them information. [Do the] same thing with community leaders. They’re just not educated in outpatient opioid treatment. Once they get some information, they seem to have a different take on it.

JB: Can you tell me what you’ve seen, particularly over the last seven years, about the types of populations that are coming to the clinics, and if that’s changed any?

KS: I started working in methadone treatment seventeen years ago. We used to have statistics on the methadone program. The average age of a person coming on the program was thirty-four years old, at that time. We had eighty or ninety people on the program and that was it. And they were long term users, primarily heroin as drug of choice. We’ve seen what’s happening over the years.

Heroin has decreased somewhat. Prescription medications went wild. I just read information that forty-four percent of patients entering methadone programs in the nation were on prescription opioids. The age of the person coming on the program has dropped from thirty-four into their late twenties. I don’t have that exact number. But we’ve seen them get younger, and we’ve seen prescription drugs take the place of heroin, in driving people into treatment.

JB: What seems to be the main type of prescription drug, or is there one?

KS: OxyContin changed the landscape in our setting. It’s still a driving force, as far as putting people into treatment. We have an increase in heroin here, but the western part of the state…OxyContin and morphine are on the scene….and any painkiller.

JB: Do you have any opinion about why that happened? Why the incidence of pain pill addiction seemed to rise over the last seven to ten years?

KS: If there’s a reason for it….I think it’s generational. It’s passed down. It’s easy. You’ve got doctors giving the mother and the father painkillers for whatever reason, legitimate or not. It gets passed on…obviously there’s a genetic link for some kinds of addiction or alcoholism. I think you know what you’re getting there [meaning a prescription pill]. People addicted to opioid drugs have very few avenues to get quality heroin in those regions of the country. [Pain pills] are a sure bet. Patients say, “I know what I’m getting when I get that pill.”

JB: If you had the ear of policy makers in Washington D.C., what would you tell them? What would you like to see happen in the treatment field for opioid addiction?

KS: I’m going to refer back to what I said earlier. In methadone treatment, there should be some kind of review, as far as what needs to be documented. Obviously, there needs to be accurate documentation, but not to put methadone or opioid treatment into the same mental health arena for documentation requirements. Because you’re dealing with a different environment, a different population, and a different caseload.

JB: Would you like to see buprenorphine play a role [at the methadone clinic]?

KS: Yes, there’s a need for it. You’ve got such a stereotype against methadone facilities, that’s another avenue for people to be in treatment [meaning buprenorphine]….whether it’s administered in the methadone facility or [community] doctor-based, there’s a need for that.

This interview was with one of the many wonderful people I’ve had the honor of working with at methadone clinics. In my years of work in the medical field, I’ve never been surrounded by as many quality people, who had passion for their work, as I have in addiction medicine. I don’t know if I’ve been extremely lucky, or if all addiction treatment centers draw dedicated individuals to work within their systems. Many of these workers try hard to dispel the stigma and social isolation that addicts feel.

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