Overdose Deaths: Opioids and Benzodiazepines

Any opioid, mixed with any benzodiazepine, alcohol, or barbiturate, can be deadly.

Part of our brainstem, the medulla, tells our bodies to breath while we sleep. Opioids inhibit the neurons (individual nerve cells) of this area of the brain, potentially interfering with this automatic breathing. This is how overdose deaths occur. People go to sleep, stop breathing, and die from lack of oxygen to main organs like the brain and the heart. Even a relatively small dose of opioid can kill a person who isn’t accustomed to taking them, and a larger dose can kill even those who are used to opioids. If you are wondering what constitutes a small or larger dose, that’s unanswerable, because of the considerable differences between individuals.

Benzodiazepines, alcohol, and barbiturates all also inhibit this same brain center, and have the potential to slow breathing, just like opioids. We don’t see many doctors prescribing barbiturates any more, with the possible exception of phenobarbital for seizures, and butalbital for headaches. Sometimes carisoprodol (Soma) is prescribed as muscle relaxant, and it gets metabolized to a barbiturate. We do see a great many people prescribed benzodiazepines, which can be dangerous for a person also taking opioids. And of course, alcohol flows freely in the U.S. society.

When a person with addiction mixes opioids with benzos, alcohol, or barbiturates, he often ends up taking more of the drug than he planned, making it easy to have a fatal overdose. Addiction is all about the loss of control. So for example, an addict may decide to take one Xanax with an opioid, but ultimately take three or four Xanax’s with the opioid. Compounding the problem, the effects of the two drugs together is usually more than would be expected, due to synergy. Synergy means that instead of 1+1=2, suddenly 1+1=4. There’s more of an effect than the person expected.

Some people are able to take both opioids and benzodiazepines without complications, but these people usually don’t have the disease of addiction, and are able to take their medication just as prescribed by their doctor. Even for these patients, benzodiazepines are rarely indicated for use for more than three months (fodder for a future blog).

But benzodiazepines can harm patients with addiction. Except for unusual circumstances, it’s a bad idea to mix any benzodiazepines with any opioid in people with addiction, because of the risk of overdose death. Rarely, a situation may arise that warrants use of benzodiazepines in a patient on opioids, but it’s for a short-term situation, and safer long-term treatments for anxiety usually can be found.

When my patients on methadone or buprenorphine (Suboxone) take benzodiazepines for anxiety, I get anxious. I worry those patients will die from an overdose. It’s a dilemma. Often, patients are clearly benefitting from methadone or buprenorphine, because they’re no longer using illicit opioids, but we now have the risk of an overdose death. So, the methadone or buprenorphine are helping them – unless it kills them… in which case it’s no longer helping.

What to do??

Some doctors say if the patient is benefitting even a small amount, because death rates are so high for opioid addicts who leave treatment, that patient should never be dismissed from a methadone clinic for using benzodiazepines.

I don’t agree with that. The first thing doctors learn in medical school is, “First, do no harm.” In other words, please try to kill as few patients as possible.

And yet, many of these patients can stop using benzodiazepines if they get the right kind of help. I ask my patients “Why do you use benzos?” and base my intervention of what they say. If they’re getting medication from a doctor, I’d like to talk to that doctor, and often a better long-term solution can be found. Benzodiazepines have very few indications for long-term use, because patients develop tolerance to the anti-anxiety properties of these medications fairly quickly. However, it’s dangerous to stop benzodiazepines suddenly in a patient who has been taking them for months or years, because of the risk of withdrawal seizures. We have to decide on the best way to handle the situation. If patients take benzos for the high it produces with methadone, they have to decide if it’s worth risking not only their treatment but their lives. If they take benzos for sleep, often I can prescribe a more suitable medication.

As long a patient has a willing spirit, and does not look like an overdose is imminent, I try to work with him or her. In each case, there are risks in stopping methadone treatment, and risks in continuing methadone treatment. The decision should be made by a physician who is well-educated and well-trained in addiction medicine. We make the best decision we can for the patient in front of us. We are the most qualified to make those – literally – life and death decisions.

The Facts About Methadone

methadone

The treatment of opioid addiction (heroin or prescription pain pills) with methadone still has an unwarranted stigma attached to it.  I wanted to devote at least one blog entry to a summary of the most well-known studies that support this evidence-based treatment. When people speak against methadone, they usually say they don’t “believe” in it, without being able to give any scientific basis for their stance. 

Well, this is why I do “believe” in it. It’s not opinion. It’s science.

 Amato L, Davoli, et. al., An overview of systematic reviews of the effectiveness of opiate maintenance therapies: available evidence to inform clinical practice and research. Journal of Substance Abuse Treatment 2005; 28 (4):321-329. In this overview of meta-analyses and other reviews, they conclude that methadone maintenance is more effective in the treatment of opioid addiction than methadone detoxification, buprenorphine, or no treatment. Higher doses of methadone are more effective than low or medium doses. 

Bale et. al., 1980; 37(2):179-193. “Therapeutic Communities vs Methadone Maintenance” Archives of General Psychiatry Opioid-addicted veterans who presented to the hospital for treatment were assigned to either inpatient detoxification alone, admission to a therapeutic community, or to methadone maintenance. One year later, patients assigned to therapeutic communities or methadone maintenance did significantly better than patients whose only treatment was detoxification. Patients in these two groups were significantly more likely to be employed, less likely to be in jail, and less likely to be using heroin, than the patients who got only detox admission. Patients in the therapeutic communities needed to stay at least seven weeks to obtain benefit equal to patients assigned to methadone maintenance. 

Ball JC, Ross A., The Effectiveness of Methadone Maintenance Treatment. New York, NY: Springer-Verlag Inc., 1991. This landmark study observed six hundred and thirty-three male patients enrolled in six methadone maintenance programs. Patients reduced their use of illicit opioids 71% from pre-admission levels, with the best results (no heroin use) seen in patients on doses higher than 70 milligrams. Longer duration of treatment with methadone showed the greatest reductions in heroin use. Of patients who left methadone maintenance treatment, 82% relapsed back to intravenous heroin use within one year. This study also found a dramatic drop in criminal activity for addicts in methadone treatment. Within one year, the number of days involved in criminal activity dropped an average of 91% for addicts maintained on methadone. This study showed that methadone clinics vary a great deal in their effectiveness. The most effective clinics had adequate dosing, well-trained and experienced staff with little turnover, combined medical, counseling and administrative services, and a close and consistent relationship between patients and staff.

 Caplehorn JRM, Bell J. Methadone dosage and retention of patients in maintenance treatment. The Medical Journal of Australia 1991;154:195-199. Authors of this study concluded that higher doses of methadone (80 milligrams per day and above) were significantly more likely to retain patients in treatment.

 Caplehorn JR, Dalton MS, et. al., Methadone maintenance and addicts’ risk of fatal heroin overdose. Substance Use and Misuse, 1996 Jan, 31(2):177-196. In this study of heroin addicts, the addicts in methadone treatment were one-quarter as likely to die by heroin overdose or suicide. This study followed two hundred and ninety-six methadone heroin addicts for more than fifteen years. 

Cheser G, Lemon J, Gomel M, Murphy G; Are the driving-related skills of clients in a methadone program affected by methadone? National Drug and Alcohol Research Centre, University of New South Wales, 30 Goodhope St., Paddington NSW 2010, Australia. This study compared results of skill performance tests and concluded that methadone clients aren’t impaired in their ability to perform complex tasks.

 Clausen T, Waal H, Thoresen M, Gossop M; Mortality among opiate users: opioid maintenance therapy, age and causes of death. Addiction 2009; 104(8) 1356-62. This study looked at the causes of death for opioid addicts admitted to opioid maintenance therapy in Norway from 1997-2003. The authors found high rates of overdose deaths both prior to admission and after leaving treatment. Older patients retained in treatment died from medical reasons, other than overdose.

 Condelli, Dunteman, 1993: examined data from TOPS, the Treatment Outcome Prospective Study, assessed patients entering treatment programs from 1979 – 1981 and found data on improvement similar to DARP; longer duration of treatment in methadone maintenance shows lower use of illicit opioids. 

Dole VP, Nyswander ME, Kreek, MJ, Narcotic Blockade. Archives of Internal Medicine, 1966; 118:304-309. Consisted of thirty-two patients, with half randomized to methadone and the other half to a no-treatment waiting list. The methadone group had much higher rates of abstention from heroin, much lower rates of incarceration, and higher rates of employment.

 Faggiano F, Vigna-Taglianti F, Versino E, Lemma P, Cochrane Database Review, 2003 (3) Art. No. 002208. This review article was based on a literature review of randomized controlled trials and controlled prospective studies that evaluated the efficacy of methadone at different doses. The authors concluded that methadone doses of 60 – 100mg per day were more effective than lower doses at prevention of illicit heroin and cocaine use during treatment.

 Goldstein A, Herrera J, Heroin addicts and methadone treatment in Albuquerque: a year follow-up. Drug and Alcohol Dependence 1995 Dec; 40 (2): p. 139-150. A group of heroin addicts were followed over twenty years. One-third died within that time, and of the survivors, 48% were on a methadone maintenance program. The author concluded that heroin addiction is a chronic disease with a high fatality rate, and methadone maintenance offered a significant benefit.

 Gordon NB, Appel PW., Functional potential of the methadone-maintained person. Alcohol, Drugs and Driving 1995; 11:1: p. 31-37. This is a literature review of studies examining performance and reaction time of patients maintained on methadone, and confirms that these patients don’t differ from age-matched controls in driving ability and functional capacity.

 Gowing L, Farrell M, Bornemann R, Sullivan LE, Ali R., Substitution treatment of injecting opioid users for prevention of HIV infection. The Cochrane Database of Systematic Reviews, 2008, Issue 2, Ar. No. CD004145. Authors reviewed twenty eight studies, concluded that they show patients on methadone maintenance have significant reductions in behaviors that place them at risk for HIV infection.

 Gronbladh L, Ohlund LS, Gunne LM, Mortality in heroin addiction: Impact of methadone treatment, Acta Psychiatrica Scandinavica Volume 82 (3) p. 223-227. Treatment of heroin addicts with methadone maintenance resulted in a significant drop in mortality, compared to untreated heroin addicts. Untreated addicts had a death rate 63 times expected for their age and gender; heroin addicts maintained on methadone had a death rate of 8 times expected, and most of that mortality was from diseases acquired prior to treatment with methadone. 

Gunne and Gronbladh, 1981: The Swedish Methadone Maintenance Program: A Controlled Study, Drug and Alcohol Dependence, 1981; 7: p. 249 – 256. This study conducted a randomized controlled trial on inpatient opioid addicts to methadone maintenance with intensive vocational rehabilitation counseling, or a control group that were referred to drug-free treatment.  Over 20 years, this study consistently showed significantly higher rates of subjects free from illicit opioids, higher rates of employment, and lower mortality in the group maintained on methadone than the control group.

 Hartel D, Selwyn PA, Schoenbaum EE, Methadone maintenance treatment and reduced risk of AIDS and AIDS-specific mortality in intravenous drug users. Abstract number 8546, Fourth Annual Conference on AIDS, Stockholm, Sweden, June 1988. This was a study of 2400 opioid addicts followed over fifteen years. Opioid addicts maintained on methadone at a dose of greater than 60mg showed longer retention in treatment, less use of heroin and other drugs, and lower rates of HIV infection. 

Hubbard RL, Marsden ME, et.al., Drug Abuse Treatment: A National Study of Effectiveness. Chapel Hill: University of North Carolina Press, 1989. Shows decreased use of illicit drugs (other than opioids) while in methadone treatment, and increased again after discharge.

 Kosten TR, Rounsaville BJ, and Kleber HD. Multidimensionality and prediction of treatment outcome in opioid addicts: a 2.5-year follow-up. Comprehensive Psychiatry 1987;28:3-13. Addicts followed over two and a half years showed that methadone maintenance resulted in significant improvements in medical, legal, social, and employment problems.

 Lenne MG, Dietze P, Rumbold GR, et.al. The effects of the opioid pharmacotherapies methadone, LAAM and buprenorphine, alone and in combination with alcohol on simulated driving. Drug Alcohol Dependence 2003; 72(3):271-278. This study found driving reaction times of patients on methadone and buprenorphine don’t differ significantly from non-medicated drivers; however, adding even a small amount of alcohol (.05%) did cause impairment.

 Marsch LA. The efficacy of methadone maintenance in reducing illicit opiate use, HIV risk behavior and criminality: a meta-analysis Addiction 1998; 93: pp. 515-532. This meta-analysis of studies of methadone concludes that methadone treatment reduces crime, reduces heroin use, and improves treatment retention.

 Mattick RP, Breen C, Kimber J, et. al.,Methadone maintenance therapy versus no opioid replacement therapy for opioid dependence. The Cochrane Database of Systematic Reviews,  2003; (2): CD002209. This is a meta-analysis of studies of methadone treatment. The authors concluded that treatment of opioid dependence with methadone maintenance is significantly more effective than non-pharmacologic therapies. Patients on methadone maintenance are more likely to be retained in treatment and less likely to be using heroin. This study did not find a reduction in crime between the two groups. 

Metzger DS, Woody GE, McLellan AT, et. al. Human immunodeficiency virus seroconversion amoung intravenous drug users in- and out- of- treatment: an 18-month prospective follow up. Journal of Acquired Immune Deficiency Syndrome 1993;6:1049-1056. Patients not enrolled in methadone maintenance treatment converted to HIV positivity at a rate of 22%, versus a rate of 3.5% of patients in methadone maintenance treatment.

 Powers KI, Anglin MD. Cumulative versus stabilizing effects of methadone maintenance. Evaluation Review 1993: Heroin addicts admitted to methadone maintenance programs showed a reduction in illicit drug use, arrests, and criminal behavior, including drug dealing. They showed increases in employment. Addicts who relapsed showed fewer improvements in these areas. 

Scherbaum N, Specka M, et.al., Does maintenance treatment reduce the mortality rate of opioid addicts? Fortschr Neurol Psychiatr, 2002, 70(9):455-461. Opioid addicts in continuous treatment with methadone had a much lower mortality rate (1.6% per year) than opioid addicts who left treatment (8.1% per year).

 Sees KL, Delucchi KL, et.al. “Methadone maintenance vs 180-day psychosocially enriched detoxification for treatment of opioid dependence” Journal of the American Medical Association, 2000, 283:1303-1310. Compared the outcomes of opioid addicted patients randomized to methadone maintenance or to180-day detoxification using methadone, with extra psychosocial counseling. Results showed better outcomes in patients on maintenance. Patients on methadone maintenance showed greater retention in treatment and less heroin use than the patients on the 180 day taper. There were no differences between the groups in family functioning or employment, but maintenance patients had lower severity legal problems than the patients on taper.

 Sells SB, Simpson DD (eds). The Effectiveness of Drug Abuse Treatment. Cambridge, MA: Ballinger, 1976: This was an analysis of information from DARP, the Drug Abuse Reporting Program, which followed patients entering three types of treatment from 1969 to 1972 and showed that methadone maintenance was effective at reducing illicit drug use and criminal activity. This study also demonstrated that addicts showed more improvement the longer they were in treatment. 

Strain EC, Bigelow GE, Liesbon IA, et. al. Moderate- vs high –dose methadone in the treatment of opioid dependence. A randomized trial. Journal of the American Medical Association 1999; 281: pp. 1000-1005. This study showed that methadone maintenance reduced illicit opioid use, and more of a reduction was seen with the addition of psychosocial counseling. Methadone doses of 80mg to 100mg were more effective than doses of 50mg at reducing illicit opioid use and improving treatment retention. 

Stine, Kosten; Medscape Psychiatric and Mental Health eJournal: article reminds us that though it’s clear that better outcomes for methadone patients are seen with higher doses (more than 80mg), many opioid treatment programs still underdose their patients.

 Zanis D, Woody G; One-year mortality rates following methadone treatment discharge. Drug and Alcohol Dependence, 1998: vol.52 (3) 257-260. Five hundred and seven patients in a methadone maintenance program were followed for one year. In that time, 110 patients were discharged and were not in treatment anywhere. Of these patients, 8.2% were dead, mostly from heroin overdose. Of the patients retained in treatment, only 1% died. The authors conclude that even if patients enrolled in methadone maintenance treatment have a less-than-desired response to treatment, given the high death rate for heroin addicts not in treatment, these addicts should not be kicked out of the methadone clinic.

 Do these studies mean that methadone works for every opioid addict? I don’t think so. Every medication has side effects and dangers. Methadone is no different. For a variety of reasons, methadone may not work for some addicts.  But this treatment has helped many addicts. At the very least, it can keep them alive until a better treatment comes along.

Description of Methadone Patients

The following is an excerpt from Chapter 2 of my book, titled, “Pain Pill Addiction: Prescription for Hope.” In this chapter I’m describing the patients I saw at methadone clinics where I worked in the years 2001 through 2009.

 I was surprised how casually people shared controlled substances with one another. As a physician, it seems like a big deal to me if somebody takes a schedule II or schedule III controlled substance that wasn’t prescribed for them, but the addicts I interviewed swapped these pills with little apprehension or trepidation. Taking pain pills to get through the day’s work seemed to have become part of the culture in some areas. Sharing these pills with friends and family members who had pain was acceptable to people in these communities.

In the past, most of the public service announcements and other efforts to prevent and reduce drug use focused on street drugs. Many people seemed to think this meant marijuana, cocaine, methamphetamine, and heroin. The patients I saw didn’t consider prescription pills bought on the street as street drugs. They saw this as a completely different thing, and occasionally spoke derisively about addicts using “hard drugs.” Most addicts didn’t understand the power of the drugs they were taking.

 Some opioid addicts came for help as couples. One of them, through the closeness of romance, transmitted the addiction like an infectious disease to their partner. Most were boyfriend/girlfriend, but some were married. The non-addicted partner’s motives to begin using drugs seemed to be mixed. Some started using out of curiosity, but others started using drugs to please their partner. I was disturbed to see that some of the women accepted the inevitability of addiction for themselves as the cost of being in a relationship with an addicted boyfriend. Often, addicted couples socialized with other addicted couples, as if opioid addiction bound them like a common fondness for bowling or dancing. Addiction became a bizarre thread, woven through the fabric of social networks.

 We saw extended family networks in treatment for pain pill addiction at the methadone clinics. One addicted member of a family came for help, and after their life improved, the rest of the addicted family came for treatment too. It was common to have a husband and wife both in treatment, and perhaps two generations of family members, including aunts, uncles, and cousins. Many addicts who entered treatment saw people they knew from the addicted culture of their area, and sometimes old disputes would be reignite, requiring action from clinic staff. Sometimes ex-spouses and ex-lovers would have to be assigned different hours to dose at the clinic, to prevent conflict.

 When the non-profit methadone clinic where I worked began accepting Medicaid as payment for treatment, we immediately saw much sicker people. Over all, Medicaid patients have more mental and physical health issues. Co-existing mental health issues make addiction more difficult to treat, and these patients were at higher risk for adverse effects of methadone. However, data does show that these sicker patients can benefit the most from treatment.

 When I started to work for a for-profit clinic, I saw a slightly different patient population. I saw more middle class patients, with pink and white-collar jobs. Occasionally, we treated business professionals. The daily cost of methadone was actually a little cheaper at the for-profit clinic, at three hundred dollars per month, as compared to the non-profit clinic, at three hundred and thirty dollars per month. However, the for-profit clinic charged a seventy dollar one-time admission fee, to cover the costs of blood tests for hepatitis, liver and kidney function, blood electrolytes, and a screening test for syphilis. The non-profit clinic had no admission fee, but only did blood testing for syphilis. I believe the seventy dollars entry fee was enough to prevent admission of poorer patients, who had a difficult enough time paying eleven dollars for their first and all subsequent days.

The patients at the for-profit clinic seemed a little more stable. Maybe they hadn’t progressed as far into their disease of addiction, or maybe they had better social support for their recovery. This clinic didn’t accept Medicaid, which discouraged sicker patients with this type of health coverage. Both clinics were reaching opioid addicts; they just served slightly different populations of addicts. The non-profit clinic accepted sicker patients, which is noble, but it made for a more chaotic clinic setting. This was compounded by a management style that was, in a few of their eight clinics, more relaxed.

 For the seven years I worked for a non-profit opioid treatment center, I watched it expand from one main city clinic, and one satellite in a nearby small town, to eight separate clinic sites. The treatment center did this because they began to have large numbers of patients who drove long distances for treatment. This indicated a need for a clinic to be located in the areas where these patients lived. Most of this expansion occurred over the years 2002 through 2006.

 Three of these clinics were located in somewhat suburban areas, within a forty-five minute drive from the main clinic, located in a large Southern city. The other four clinics were in small towns drawing patients from mostly rural areas. One clinic was located in a small mountain town that was home to a modest-sized college. Nearly all of the heroin addicts I saw in the rural clinics were students at that college. But by 2008, we began to see more rural heroin addicts, who had switched from prescription pain pills to heroin, due to the rising costs of pills.

Within a few years, clinics near the foothills of the Blue Ridge Mountains of Western North Carolina were swamped with opioid addicts requesting admission to the methadone clinics. These clinics soon had many more patients than the urban clinic.

I saw racial dissimilarities at the clinic sites. In the city, we admitted a fair number of African Americans and other minorities to our program. Most of them weren’t using pain pills, but heroin. I don’t know why this was the case. Perhaps minorities didn’t have doctors as eager to prescribe opioids for their chronic pain conditions, or perhaps they didn’t go to doctors for their pain as frequently as whites. If they were addicted to pain pills, maybe distrust kept them from entering the methadone clinic. In the rural clinics, I could count the number of African-American patients on one hand. They were definitely underrepresented. The minorities we did treat responded to treatment just as well.

A recent study of physicians’ prescribing habits suggested a disturbing possibility for the racial differences I saw in opioid addiction. (1) This article showed statistically significant differences in the rate of opioid prescriptions for whites, compared to non-whites, in the emergency department setting. Despite an overall rise in rates of the prescription of opioid pain medication in the emergency department setting between 1993 and 2005, whites still received opioid prescriptions more frequently than did Black, Asian, or Hispanic races, for pain from the same medical conditions. In thirty-one percent of emergency room visits for painful conditions, whites received opioids, compared to only twenty-three percent of visits by Blacks, twenty-eight percent for Asians, and twenty-four percent for Hispanic patients. These patients were seen for the same painful medical condition. The prescribing differences were even more pronounced as the intensity of the pain increased, and were most pronounced for the conditions of back pain, headache, and abdominal pain. Blacks had the lowest rates of receiving opioid prescriptions of all races.

This study could have been influenced by other factors. For example, perhaps non-whites request opioid medications at a lower rate than whites. Even so, given the known disparities in health care for whites, versus non-whites in other areas of medicine, it would appear patient ethnicity influences physicians’ prescribing habits for opioids. The disparities and relative physician reluctance to prescribe opioids for minorities may reduce their risk of developing opioid addiction, though at the unacceptably high cost of under treatment of pain.

Interestingly, we had pockets of Asian patients in several clinics. We admitted one member of the Asian community into treatment, and after they improved, began to see other addicted members of their extended family arrive at the clinic for treatment. Usually the Asian patients either smoked opium or dissolved it in hot water to make a tea and drank it. When I tried to inquire how much they were using each day, in order to try to quantify their tolerance, the patient would put his or her thumb about a centimeter from the end of the little finger and essentially say, “this much.” Having no idea of the purity of their opium, this gave me no meaningful idea of their tolerance, so we started with cautiously low doses.

One middle aged patient from the Hmong tribe presented to the clinic and when I asked when and why he started opioid use, in broken English and with difficulty, he told me he had lost eight children during the Vietnam War, and was injured himself. After the pain from his injury had resolved, he still felt pain from the loss of his family and he decided to continue the use of opium to treat the pain of his heart, as he worded it. I thought about how similar his history was to the patients of the U.S. and how they often started using opioids and other drugs to dull the pain of significant loss and sorrow. I thought about how people of differing ethnicities are similar, when dealing with addiction, pain, and grief.

1. Pletcher M MD, MPH, Kertesz, MD, MS, et. al., “Trends in Opioid Prescribing by Race/Ethnicity for Patients Seeking Care in US Emergency Departments,” Journal of the American Medical Association, 2008 vol. 299 (1) pp 70-78.

Me, Behaving Badly

So there I was, happily seeing patients in one of the methadone clinics where I work. I was adjusting doses, doing a few admissions, and it was a good day.

A patient came in for a dose check, and mentioned that she was turned down for a job because she’s on methadone. At that, my inner agitator perked up. Of course, I had to get the details. My patient said she interviewed for a job at a doctor’s office, and told him she was on methadone. He said she must sign a contract with him, agreeing to decrease her dose by five milligrams a day (!) before she could come to work for him. And if she didn’t do this, he wouldn’t hire her. And he told her the usual steaming pile of crap, that the methadone clinic was nothing but a dope dealer who wanted all her money (does he treat people for free?) yada yada. And that he could cure her addiction with a quick colon cleanse.

Sometimes I wonder if the patients just tell me these things to watch me go into orbit.

But with that last bit about a colon cleanse, I knew we could not be dealing with a physician. I went to my state’s website for doctors. Sure enough, no such M.D. was listed with his name. So I called his office and asked to speak with him. I also asked the lady answering the phone if the doctor was licensed by any board and she said yes, the chiropractic board and some alternative medicine board.

Finally, he came to the phone. I told him that my patient said he instructed her to get off of methadone, and was this true. He said yes, because he couldn’t hire someone addicted to narcotics, and she told him the clinic wanted her to stay on methadone long-term. He said it was so bad for her, no better than heroin, and he knew about heroin because he was over fifty years old and remembered heroin……He really wasn’t making any sense, and I stopped listening. Like one of those cartoon characters who has smoke coming out his ears from anger, I exploded.

“I don’t appreciate you giving bad medical advice to one of my patients. You don’t know what you’re talking about, and you need to educate yourself before you give anyone else terrible information, MR. X (name deleted to protect the guilty). What you did is also against the law. You can’t discriminate against someone who is legally prescribed methadone to manage a medical problem, addiction. Addiction is an illness protected by the Americans with Disabilities Act. And treatment of opioid addiction with methadone has been around for forty-five years, with piles of evidence-based studies to prove it works…”

The conversation went downhill from there. The best thing I can say for myself is that I didn’t swear at him. The worst is that I finally hung up on him.

This is not the way I prefer to conduct myself. I’ve always found it better to try to gently educate people, and if they aren’t receptive, thank them and get off the phone, accepting their close-mindedness. But today I couldn’t seem to stop myself. It’s as if all my frustrations, caused by seeing patients in good recovery treated like criminals because they selected methadone treatment, all came out in one big stinking mess of verbiage. It wasn’t my finest hour, but it sure felt good at the time. And in the long run it will accomplish little.

If I had it to do over again, I’d try to remain pleasant, and disperse bits of information between his confusing statements. I’d offer to mail some material so that he could become better acquainted with what we do. I’d tell him of the proven benefits of treatments, as well as the limitations, because methadone isn’t right for every opioid addict. I would have sounded more like a sane human being and less like a foam-at-the-mouth-zealot. Hopefully I’ll handle myself differently next time. After all, doctors need to learn and grow, too.

Judges Behaving Badly

When a valid form of addiction treatment is criticized by someone who knows next to nothing about it… I nearly always go into a dither. I’m better than I used to be, but not much.

Recently, a patient at one of the methadone clinics where I work said he appeared before a judge for offenses committed prior to entry into treatment at the methadone clinic. The patient says the judge ordered him to get off methadone as part of his sentence, which also included public service, intensive probation, and monetary fines. I’m going to make sure the patient’s report is accurate before I begin my literary assault by letter. But I suspect the judge actually said what my patient reports.

It amazes me a judge would foolishly practice medicine, by dictating what an opioid addict, ill with a disease, can or cannot do to get treatment for their disease.

It’s not like methadone is a flash in the pan. It’s been around for 45 years. It’s one of the heaviest evidence-based treatments in all of medicine. Plus, we have several studies showing opioid addicts who leave methadone treatment have a death rate at least eight times higher than opioid addicts who stay in methadone treatment. (1, 2)

 That’s death rates. And dead addicts don’t recover.

If other equally effective options were available to this young man, I wouldn’t be as upset by the judge’s ruling. If the patient could afford to stay in a medical detoxification unit for seven to ten or more days, followed immediately by prolonged inpatient residential drug rehabilitation of thirty to ninety days, I might agree with the judge. But this young man can’t afford that kind of treatment. State funded treatment exists, but usually patients can stay a week in a detox and one, maybe even two weeks in rehab, which is rarely enough for an opioid addict. Outpatient treatment, without replacement medication, results in relapse rates consistently shown to be in the range of 96%.

In my letter to the judge I’m going to try to gently educate, which seems to be the best approach to the law and order type people. In my letter to the judge I’m going to cite several studies, and direct the judge towards an excellent NIDA (National Institute on Drug Abuse) website with all essential information regarding treatment of opioid addiction with methadone: http://international.drugabuse.gov/collaboration/guide_methadone/index.html

This wonderful tool, in a question and answer format, contains valuable information about methadone and its use in the treatment of opioid addiction. It contains references to all of the best and most commonly cited studies about methadone. If you have questions, check it out.

1. Scherbaum N, Specka M, et.al, Does maintenance treatment reduce the mortality rate of opioid addicts? Fortschr Neurol Psychiatr, 2002, 70(9):455-461.

2. Zanis D, Woody G; One-year mortality rates following methadone treatment discharge. Drug and Alcohol Dependence, 1998: vol.52 (3) 257-260.

Law Enforcement Behaving Badly

Many law enforcement personnel and members of the legal community resist medication-assisted treatments. They seem to have difficulty letting go of their idea that addiction is a choice that deserves blame, and have a punitive stance towards addicts. I find it difficult to work with these professionals. They have low opinions of addicts who are using drugs, but often have no better opinion of a recovering addict who has sought treatment and is doing well on replacement medications, like methadone or buprenorphine. Law enforcement personnel have ways of letting methadone patients know they are regarded as if they’re still using drugs.

            When I worked at a methadone clinic in the mountains of North Carolina, we had a Tennessee resident, a pregnant woman, who committed a crime before she sought treatment at our methadone clinic. By the time she was sentenced to three months of incarceration, she was seven months pregnant. She asked to begin her sentence after delivering her child and her request was denied by the judge. He said he would cure her addiction by placing her in jail and then, at least, the baby wouldn’t be born addicted to methadone. He had been informed she was in treatment at a methadone clinic in North Carolina.

The patient contacted her counselor at the methadone clinic, in a panic, because she knew she could miscarry if denied methadone.  Opioid withdrawal could even kill her fetus. Her counselor called me and related all of the details.

I was surprised that a judge would make a medical decision like that, and if he did, it was only because he didn’t have information about methadone. I called the judge’s office, but couldn’t get through to him. I explained everything to his clerk, and believed the patient would either be given methadone in jail or have her sentence postponed.

The next day the patient called, and said she was still going to start her sentence in two days, and that the judge hadn’t changed his mind. I called the judge again, and was told the judge wasn’t going to come to the phone to speak with me, the clerk had relayed the message, the mother was going to jail and no, she would not be given methadone.

Now irritated and worried, I composed a letter, detailing the possible medical complications that could occur, as a result of the judge’s uninformed and ill-advised decision, and told him this was a medical decision that should be made by doctors. I described the preterm labor that could occur, if the mother was allowed to go into withdrawal. The fetus may not be able to survive if born at seven months’ gestation. I ended with a plea that no matter what he thought of the mother, the baby at least should be given the best chance for survival. I faxed a copy to the judge and a copy to the patient’s lawyer. Later, I heard she was allowed to deliver a healthy baby boy, prior to beginning her three month sentence.

Recently, I was asked to speak at an addictions conference, in the heart of the Blue Ridge Mountains, about methadone and its use in the treatment of opioid addiction. The speaker who gave a presentation after me was a lawyer with the local drug court. He explained how drug court got addicts, who committed crimes related to drug use, to participate in treatment, rather than just sending them to jail.

During the question and answer session, he was asked if patients on methadone could participate in the drug court program. He said no. When asked why this was, he said that to participate, the addicts must be completely drug free. Another member of the audience asked why this was the case, if methadone was a legitimate treatment and it had been started by a physician.

            The lawyer did not give a clear answer, but turned to the program director of a local outpatient treatment center, sitting in the audience.  The drug court contracts with this outpatient treatment center, to provide the counseling needed for the addicts participating in drug court. This program director said that addicts on methadone couldn’t come to the counseling his center provided because they “would give their methadone to other patients and nod off in treatment sessions.”      

            This was a clear example of the biases methadone patients face. I had just completed a lecture about methadone and had explained how opioid treatment center patients don’t receive take home doses for at least the first three months, and how patients on the right dose are not sedated, unless they use nerve pills or other sedatives. In the above case, both the court and the treatment program were opposed to methadone, and they didn’t have a clear policy on buprenorphine.

            That said, at present, the majority of drug courts don’t allow participants to be on methadone, though methadone has been shown to be very cost effective as well as beneficial to opioid addicts.

            At Rikers Island, in New York City, opioid-addicted prisoners charged with misdemeanors or low grade felonies can be enrolled in a program known as KEEP (Key Extended Entry Program). This program treats opioid addicts with methadone and counseling. Upon release from Rikers Island, these patients are referred to methadone treatment centers in the community. Seventy-six percent have followed through with their treatment, post-release. The results of this program show significant reduction in reincarceration and significant reduction in criminal activity.

            Drug courts would be well-advised to look at the Rikers Island program, for an example of the effectiveness of methadone maintenance. They should also consider the amount of money it can save the community. Studies have shown a cost savings of at least four dollars for every one dollar spent on methadone treatment. This money is saved because methadone patients require fewer days of hospitalization and other healthcare costs, and also because of reduction in criminal activity and incarceration costs. (1)

            Many jails will not dispense methadone to prisoners who are patients in at a methadone clinic, even if they are doing well and on a stable dose. Many times, these patients are allowed to go through a terrible withdrawal. Patients tell me they have been taunted for being ill from withdrawal from methadone, and refused access to medical care. This refusal to treat an illness with an accepted and effective medication has been costly to at least one county in Florida.

            In 1997, an Orange county jail inmate died after being denied her usual dose of methadone. She spent twelve days in withdrawal, before she was found dead in her cell. The family sued the county and won a three million dollar settlement. (2) Then in 2000, a second person died in the very same Orange county jail, under nearly identical circumstances. (3) She had been a patient at a methadone clinic for about five months, before entering the jail. She was denied her medication, and was found unconscious three days later, from an apparent seizure. She was then taken to a hospital, and her family removed her from life support five days later.

            In 2001, Orange County decided to offer methadone to patients who were already established at a methadone clinic, and continue their dosing. They’ve worked out arrangements with a local methadone clinic to provide the necessary methadone. Opioid addicts who are not established in any kind of treatment are treated with a standard opioid withdrawal protocol. Soon, Orange County may begin to use buprenorphine in this jail setting.                                                                                                                                                              More jail facilities would be wise to heed the experience of Orange County.

            In Cook County, Illinois, a man serving a ten day sentence for a traffic violation died of methadone withdrawal on his sixth day of imprisonment. He was an established patient of a methadone clinic, but the jail refused to provide his methadone medication. He made repeated requests for medical attention, but was denied care, despite his obvious physical suffering, witnessed by at least three jail employees. (4) He died of a cerebral aneurysm, as a result of opioid withdrawal. His wife and estate sued the county, for failing to provide timely medical treatment, charging them with deliberate indifference to the suffering of the prisoner. 

I’m glad to see these lawsuits. I’ve heard appalling stories from many methadone patients, who were denied their medication while incarcerated. I’ve heard tales of jailers taunting these prisoners, when they became sick. There is no defense for such cruelty.

            On a positive note, more jails and prisons across the U.S. are beginning to offer access to medication assisted therapies, with both methadone and buprenorphine. Colorado has several counties that coordinate care with local treatment centers. A clinic within Albuquerque’s city detention center offers treatment with methadone. Rhode Island’s department of corrections contracts with a local treatment center, to treat opioid addiction. The jail in Seattle-King County, Washington, plans to offer both methadone and buprenorphine soon.

            Will this country ever become civilized enough to provide appropriate medical care to patients on replacement medications while they are in jail? I hope so. Sadly, it appears that litigation is the only way to get the attention of some jail facilities.

1. California Department of Drug and Alcohol Programs, 2004, California drug and alcohol treatment assessment (CALDATA) California Department of Alcohol and Drug Programs. California Drug and Alcohol Treatment Assessment (CALDATA), 1991-1993 [Computer File]. ICPSR02295-v2. Ann Arbor, MI: Inter-university Consortium for Political and Social Research [distributor], 2008-10-07. doi:10.3886/ICPSR02295
2. “Outrageous: the death of Susan Bennett raises serious questions about the competence and quality of the jail’s nursing staff” Orlando Sentinel, editorial, March 27, 1998.
3. Doris Bloodsworth, “Inmate begged for methadone” Orlando Sentinel July 12, 2001.
4. Davis vs Carter, #05-1695 US Court of Appeals, Seventh Circuit http://openjurist.org/452/f3d/686/davis-v-carter

Interview with a Methadone Counselor

I met a skilled drug addiction counselor, previously addicted to heroin, who became abstinent from all drugs, by going to meetings of Narcotics Anonymous. She had been a patient of methadone clinics off and on for many years, prior to getting clean. I met her after she had more than ten years of completely abstinent recovery, yet she happily works at a methadone clinic, helping opioid addicts. I interviewed her because of her personal experience and her striking open-mindedness to different approaches to the treatment of addiction. Here is what she had to say about her experiences with methadone, and her perspective:

JB: Can you please tell me your personal experience of opioid addiction?
RJ: Well, my personal experience began at the age of…probably eighteen….and I was introduced by some people I was hanging out with. I was basically very ignorant about those kinds of things. I wasn’t aware of that kind of stuff going on, ‘cause I was raised in this real small town and just didn’t know this kind of stuff happened.
My first experience was with a Dilaudid. Somebody said we had to go somewhere else to do it, and I really didn’t understand that, because I certainly didn’t know that it would be injected. That was my first experience with a narcotic, with opiates, and….I fell in love!
I loved it. I injected it, and the feeling was…..like none I had ever felt. And even though I did get sick, I thought it was what I was looking for. It was the best feeling in the world.
Obviously, they didn’t tell me about getting sick, [meaning opioid withdrawal] and that after doing it for some days consecutively, when you didn’t have any, you’d get sick. I never will forget the first time I was sick from not having any.
And that lead to a habit that lasted twenty-some years. My experience and my path led me down many roads… with addiction, going back and forth to prison, because I obviously didn’t make enough money to purchase these drugs that I needed to have in my body, to keep from being sick. This lasted for twenty four years. I ended up doing heroin and I liked it, because it tended to be stronger. Morphine I liked a lot, but it wasn’t easily accessible, so I switched over to heroin at some point. Which I liked a lot.
JB: What role did methadone play in your recovery?
RJ: I’ve been in numerous methadone clinics. I typically would get on methadone when I got a charge [meaning legal problems] and I wanted to call myself being in treatment. I never ever got on methadone with any expectations, hopes, or thoughts of changing my life. I got on because it kept me from being sick. And it kept me off the street for a period of time. If I had a charge, I was in treatment and I always thought that would help me in my journeys with the legal systems. That was the part methadone played in my life, it was just to help me get through it.
JB: Did it help you?
RJ: At the time, it did. My problem with methadone was, when I would get on methadone, I would tend to do cocaine, because I could feel the cocaine, and I wasn’t about changing anything. I just wanted temporary fixes in my life. I’d switch to cocaine while I was on methadone. And it [methadone] worked for a time. I never got any take homes, because I continued to test positive for other substances while I was on methadone, but I thought I was doing better, ‘cause I was not doing narcotics. In that aspect it did help.
JB: And you’ve been in recovery from addiction now for how long?
RJ: It will be fifteen years in June.
JB: Wonderful!
KS: Yes, it is wonderful.
JB: And tell me where you work now.
RJ: I work at a methadone treatment facility.
JB: How long have you been working there?
RJ: I’ve been there for almost fourteen years and in this [satellite] clinic for a little over two years, and I’ve been in methadone [as a counselor] for five years.
JB: How do you feel about methadone and what role it should play in the treatment of opioid addiction?
RJ: I believe in methadone. Our [her clinic’s] philosophy certainly is not harm reduction but I believe that’s what it’s about. And I do believe that those people on methadone, and are doing well, have a home, have a life, I think that’s all they aspire to. For them that’s enough, you know, they’re not out ripping and running the roads, they’re not looking for drugs on a daily basis. They come and get their methadone, they go to work, they have a life, they have a family, they have a home, and for them that’s good enough.
JB: Do you think it keeps them from getting completely clean [I purposely chose to use her language to differentiate being in recovery on methadone from being in recovery and completely off all opioids]?
RJ: No. I think they know they have a choice.
JB: OK
RJ: I really believe that a lot of them don’t think that they can ever do anything differently, and I know from personal experience that can be very true. I think that you just get so bogged down in your disease that you don’t see any way out. I think if you can find a place where you can get something legally and you’re not using the street drugs, and you’re not out copping [buying drugs] and you’re working and basically having a life, then that becomes OK, and that becomes good enough.
And addicts by nature are scared of change, and they get in that role and they get comfortable and that’s good enough for them. So I don’t believe they think that they can do any better.
JB: What percentages of your patients have already used street methadone by the time they get to the clinic?
RJ: I’d say seventy-five percent. Very rarely do I do an assessment [on a new patient] that somebody hasn’t already used methadone on the street. Very rarely.
JB: What are your biggest challenges where you work?
RJ: Actually my biggest challenges where I work are internal challenges. Fighting that uphill battle of no consequences for clients. There’s no consequences. We allow them to do basically what they want to do. [She is speaking of her methadone clinic’s style of interaction with patients].
JB: Do you think patients did better when there were a few consequences?
RJ: Oh yeah. Yeah. I mean, when certain clients can continue to have the same behaviors, like use benzos [meaning benzodiazepines like Valium and Xanax] and there are no consequences, certainly they are going to continue doing those behaviors. And those are the things that are challenges now, for us, for me.
I can’t enforce any consequences because we’re not allowed to, because it’s called punishment. The powers that be, they see it as punishment, where I work. Being that I come from living a life of doing the wrong thing always, I’m a big believer in consequences. And I believe that if you don’t have any, you continue to do those things. That’s the kind of stuff, the inadequacies where I work at.
JB: What do you like most about your job?
RJ: (pause) The light…. in somebody’s eyes every now and again. It might not happen much, but now and again the light comes on, and you have that “ah ha” moment. They have it, and you’re like, yes! Or when somebody comes and tells you they have that little spark of hope. Yep. That’s what I like most about my job.
JB: If you could make changes in how opioid addiction is treated, what would you do? If you could tell the people who make the drug laws, what would you recommend? How would you change the system, or would you?
RJ: I don’t know that I would change the system. I think the system works. I think it’s individual facilities that don’t work sometimes. Yeah. I think – methadone’s been around a long time – I mean, obviously it’s worked for a lot of years or it wouldn’t still be in existence. I think methadone maintenance programs work, but each individual facility maybe needs to make changes. You know, that’s just my opinion.
JB: If you were the boss of a methadone treatment center, how would you handle benzodiazepine use by patients?
RJ: They wouldn’t be tolerated. At all.
JB: Why is that?
RJ: Because I think they kill people. I know they kill people.
JB: How about alcohol?
RJ: Alcohol wouldn’t be tolerated either. I mean, obviously you would be given a chance to straighten it and rectify it and clean it up, with help, if you need it. But that would be it. You would get that opportunity and then [if the patient couldn’t stop using alcohol] you would be detoxed from that program. I believe that’s the route to go. We’ve had too many deaths. And there’s nothing to say that it’s not going to continue to happen…so, yeah, if I had a facility it would not be tolerated. There would be zero tolerance, period. There just wouldn’t be any.
JB: What do you say to people that say that’s keeping people out of treatment?
RJ: There are other types of treatment; maybe you need a different level of care. Maybe methadone’s not the answer.
JB: So you don’t think methadone’s the answer for every opioid addict?
RJ: No. No I don’t.
JB: What do you think about people on methadone coming to Narcotics Anonymous?
RJ: I think they have a right to come to Narcotics Anonymous.
JB: Do you think they should share?
RJ: I wish they could share, but I know, there again from personal experience, how methadone is viewed by people in Narcotics Anonymous. And I think that if that person does share [that they are on methadone], they are treated differently.
JB: Do you tell your patients to go to NA?
RJ: I do.
JB: What do you tell them about picking up chips?
RJ: That’s their personal call, because I feel like it is. But then I don’t view methadone as using. See, I look at it as treatment, and somebody taking medication because they’re sick, and trying to get better. So I don’t view that as getting up and doing dope. Therefore if I were on methadone and going to meetings, I’d pick up chips.
JB: Can you think of anything else [you’d like to say]?
RJ: I believe in methadone. I really do. I just believe that it works. I know people who have been on our program for twenty years, and granted, those people will never get off methadone, but they have a life today. And twenty years ago they didn’t have one. They’re not perfect but I’m not either, you know, just ‘cause I don’t use dope any more. But they’re still suffering addicts, just like I am. So I just believe that methadone works, and if you want to make changes in your life, that there are people at every facility who are willing to help you make those changes.

Treatment professionals can also make the mistake of dismissing non-medication treatment of opioid addiction as ineffective, when clearly this is not true. Though treatment with methadone and buprenorphine can provide enormous benefit, so can the other medication-free forms of treatment. And as we have seen, methadone can cause great harm when used inappropriately, and some opioid addicts don’t do well on methadone.
There’s no one best treatment path for every addict. Every evidence-based treatment helps some addicts.

Which is better, Suboxone or methadone?

 

Patients often ask which medication is better to treat opioid addiction: methadone or Suboxone? My answer is…it depends.

 First of all, the active drug in Suboxone is buprenorphine, and I’ll refer to the drug by its generic name, since a generic has entered the market. We’re no longer just talking about one name brand.

 The principle behind both methadone and buprenorphine is the same: both are long-acting opioids, meaning they can be dosed once per day. At the proper dose, both medications will keep an opioid addict out of withdrawal for 24 hours or more. This means instead of having to find pain pills or heroin to swallow, snort, or shoot three or four times per day, the addict only has to take one dose of medication. Addicts can get back to a normal lifestyle relatively quickly on either of these medications. Both methadone and buprenorphine are approved by the FDA for the treatment of opioid addiction, and are the only opioids approved for this purpose.

Buprenorphine is safer then methadone, since it’s only a partial opioid. A partial opioid attaches to the opioid receptors in the brain, but only partially activates them. In contrast, methadone attaches to opioid receptors and fully stimulates them, making it a stronger opioid. Because buprenorphine is a partial opioid, it has a ceiling on its opioid effects. Once the dose is raised to around 24mg, more of the medication won’t have any additional effect, due to this ceiling. But with methadone, the full opioid, the higher the dose, the more opioid effect.

 Because buprenorphine is a safer medication, the government allows it to be prescribed in doctors’ offices, but only if the doctor has taken a special training course in opioid addiction and how to prescribe buprenorphine, or can demonstrate experience with the drug. This office-based treatment of addiction has a huge advantage over treatment at a traditional methadone clinic. Treatment in a doctor’s office doesn’t have to follow the strict governmental regulations that a methadone clinic must follow. Methadone clinics have federal, state, and even local regulations they must follow, and patients have to come to the clinic every day for dosing, until a period of months, when take home doses can be started for weekends.

 The law allowing buprenorphine to be prescribed for opioid addicts from offices instead of clinics was passed in 2000. It was hoped that relatively stable opioid addicts would get treatment at doctors’ offices, and addicts with higher severity of addiction would still be treated at methadone clinics.

 But it hasn’t worked out quite like that. Because buprenorphine is relatively much more expensive than methadone, addicts with insurance or money go to buprenorphine doctors’ offices, and poor addicts without insurance go to methadone clinics. Rather than form of treatment being decided by severity of disease, it’s decided by economic circumstance. This means that some of the opioid addicts being treated through doctors’ offices really aren’t that stable, and have been selling their medication, making it a desirable black market drug. Most of the addicts buying illicit buprenorphine have been trying to avoid withdrawal or trying the drug before paying the expense of starting it.

 Treating opioid addicts for the last nine years, I’m continually surprised at how people’s physical reactions to replacement medications are dissimilar. Some patients don’t feel well on buprenorphine, but feel normal on methadone. For other patients, it’s just the opposite. For many, either medication works well.

 Addicts (and their doctors) tend to assume that all opioid addicts will be the same in their physical reactions to these replacement medications, but they aren’t. For example, last week I saw a lady who insisted she’s never had physical withdrawal symptoms from methadone. But most patients find methadone withdrawal to be the worst of all opioids.

 And sometimes I have a patient I expect will do very well on buprenorphine, but they don’t. they feel lousy.

 So the answer to question of which medication is best – buprenorphine is safer, and not as strong an opioid, so it’s the preferred medication. It’s also more convenient, but much more expensive at present. But a great deal depends on the patient, and how she reacts to medications.

 Neither medication is meant to be the only treatment for opioid addiction. Best results are seen when these medications are used along with counseling, to help the addict make necessary life changes.

Urine Drug Screens for methadone and Suboxone (buprenorphine)

Many patients who are prescribed methadone or buprenorphine (better known to some as Suboxone) are concerned about their employment drug screens. Because of the stigma attached to opioid addiction and its treatment with methadone or buprenorphine, patients don’t want their employers to know about these medications, and thus about their history of addiction.

Most companies who do urine drug screening hire a Medical Review Officer (MRO), who is a doctor specifically trained to interpret drug screen results. This doctor is a middle man between the employer and the employee, and though this doctor may ask for medical information, and information about valid prescriptions, this doctor usually can’t tell the employer this personal information. The MRO reports the screen as positive or negative, depending on information given to her.

Most employment urine drug screens check for opiates, meaning naturally-occurring substances from the opium poppy, like codeine and morphine. Man-made opioids like methadone, buprenorphine, and fentanyl, to name a few, won’t show as opiates on these drug screens.

A few employers do drug screening that specifically checks for hydrocodone or oxycodone. This is infrequent. It’s rare for employers to screen for methadone, and they almost never screen for buprenorphine, unless the patient is a healthcare professional being monitored by a licensing agency. The screen for buprenorphine is pricey, so the only doctors who tend to screen for it regularly are the ones prescribing buprenorphine. These doctors want to make sure their patients are taking, not selling, their medication.

Patients ask if they should tell their employer they are on methadone or buprenorphine. In general, that’s probably a bad idea, unless it’s a special situation. So long as you can do your job safely, your medical problems aren’t any of your boss’s business.

The only exceptions to this are if you work in a “safety sensitive” job. This includes medical professionals, transit workers, pilots, and the like. These jobs may require disclosure of medical issues to protect public safety. For example, to get a commercial driver’s license (CDL), you have to be free from illnesses which may cause a sudden loss of consciousness behind the wheel.

The Dept. of Transportation still says that if you are taking methadone for the treatment of addiction, you can’t be granted a CDL. However, most of the studies done on methadone-maintained patients shows their reflexes are the same as a person not on methadone, so there’s no real scientific reason for the DOT’s decision. (1, 3, 4) Besides, since the urine drug screen for a driver’s physical doesn’t include methadone, they won’t know unless you tell them.

Patients can be impaired, and unable to drive safely, if they have just started on methadone, haven’t become accustomed to it, or are on too high a dose. These patients shouldn’t be behind the wheel until they are stable, even in a car, let alone an 18-wheeler. Methadone patients are likely be impaired and unable to drive if they abuse benzodiazepines. They shouldn’t drive any kind of vehicle. Ditto for alcohol. (2, 5)

1. Baewert A, Gombas W, Schindler S, et.al., Influence of peak and trough levels of opioid maintenance therapy on driving aptitude, European Addiction Research 2007, 13(3),127-135. This study shows that methadone patients aren’t impaired at either peak or trough levels of methadone.

2. Bernard JP, Morland J et. al. Methadone and impairment in apprehended drivers. Addiction 2009; 104(3) 457-464. This is a study of 635 people who were apprehended for impaired driving who were found to have methadone in their system. Of the 635, only 10 had only methadone in their system. The degree of impairment didn’t correlate with methadone blood levels. Most people on methadone who had impaired driving were using more than just methadone.

3.Cheser G, Lemon J, Gomel M, Murphy G; Are the driving-related skills of clients in a methadone program affected by methadone? National Drug and Alcohol Research Centre, University of New South Wales, 30 Goodhope St., Paddington NSW 2010, Australia. This study compared results of skill performance tests and concluded that methadone clients aren’t impaired in their ability to perform complex tasks.

4.Dittert S, Naber D, Soyka M., Methadone substitution and ability to drive. Results of an experimental study. Nervenartz 1999; 70: 457-462. Patients on methadone substitution therapy did not show impaired driving ability.

5.Lenne MG, Dietze P, Rumbold GR, et.al. The effects of the opioid pharmacotherapies methadone, LAAM and buprenorphine, alone and in combination with alcohol on simulated driving. Drug Alcohol Dependence 2003; 72(3):271-278. This study found driving reaction times of patients on methadone and buprenorphine don’t differ significantly from non-medicated drivers; however, adding even a small amount of alcohol (.05%) did cause impairment.

Doctors Behaving Badly

Yesterday, one of the opioid treatment clinic patients told me about a bad experience she had with a local doctor in the emergency room.  

 She went to the ER for a mild medical ailment that required an antibiotic. It wasn’t a severe illness, but couldn’t wait until she could be seen at her family doctor’s office. She didn’t ask for pain medication. In fact, she went out of her way to let the doctor know she’d had a pain pill addiction problem, and was now taking methadone, prescribed by our treatment center.

 This lady is doing very well on a moderate dose of methadone. She’s been free from illicit opioids for about five months. She participates in her treatment by seeing her counselor at least once a week. She works every day, and has been saving money to buy a more dependable car. She’s been able to participate in local family gatherings, which is something she hadn’t been able to do while in active addiction.

 She says this ER doctor, whom she had never met before,  told her she needed to “get off that stuff,” referring to methadone. He disparaged the methadone clinic and said we were “legal dope dealers.” She says he spent more time haranguing her about methadone  than he did addressing the illness for which she sought treatment.

 I know he was trying to do what’s right for his patient. But maybe he should make an effort to read the evidence, the vast body of evidence, supporting the treatment of opioid addiction with methadone, before shooting off his mouth.

 It’s so vexing.

 And yet, I should be more understanding. Doctors aren’t taught much about diagnosing addiction, and even less about treating it. Before I became interested in treating addiction, I knew little about it. But then, I never launched into a tirade against medication I wasn’t familiar with, as far as I can remember.

 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 the doctors are open-minded and receptive to information, and sometimes not. 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 lack of information, and have compassion for other doctors, who probably know as little about it as I did, before I worked at an opioid treatment center.

 I suspect I’m not only outraged for my patients, but also for myself. It does sting when colleagues criticize what I do for a living. Maybe I need to learn, just as the patients have, that the only person who needs to be OK with me is me. Many times, the world doesn’t applaud when we are doing what we know is right. And we need to accept that and get on with our lives anyway.