Methadone Clinics Behaving Badly

Not all methadone clinics are equal. We know what qualities are associated with the best outcomes, and hopefully every clinic is trying to improve.

First, many clinics should be called “opioid treatment centers,” because they offer more than methadone; they also prescribe and dispense buprenorphine. In the future, buprenorphine will likely be the first line treatment for opioid addiction replacement medication, with methadone saved for people who don’t do well on buprenorphine, usually because it’s not strong enough. In the very near future, buprenorphine may replace methadone as the treatment of choice for opioid-addicted pregnant patients.

Besides the ability to offer buprenorphine, the best clinics have well-trained staff with low turnover. This seems obvious. It’s difficult for a patient to participate in counseling with enthusiasm when they’ve had three different counselors within four months. Sadly, this is an area of counseling that has difficulty retaining counselors.

 And while we always need to be open to learn from our patients, a counselor should already know the basics about opioid addiction and its treatment with replacement medications before he sees the first patient. I’ve heard the occasional counselor voice doubts about the benefits of replacement medications. If the counselor can’t wholeheartedly support their patients, they need to go back and read the basic research, or move on to a different field. An ambivalent and uninformed counselor can taint the treatment milieu at an otherwise good clinic.

Doctors prescribing the methadone or buprenorphine should be willing to give adequate doses. Clinics who were stingy with dosing had worse patient outcomes in many studies. In the past, clinics were reluctant to dose above 60 or 70mg, but we know now that patients do better at adequate doses, and there’s a wide variation between patients as to what’s an adequate dose. Most patients stabilize on between 80 to 120mg, but some need much more and some need much less. Cookie cutter dosing isn’t best practice.

Counselors shouldn’t have overwhelming caseloads. The regulations say each counselor should have no more than 50 patients, but even that’s too many with the growing documentation requirements.

Clinics shouldn’t let a few patients, not doing well and causing chaos in the community, to remain in the clinic, dosing daily with methadone or buprenorphine. The reputation of opioid treatment centers is too important and too fragile. In many communities, laws have been passed to limit the number and type of drug addiction treatment centers, because of the community’s perception that the patients will create havoc locally. In reality, very few patients behave like this, but the ones that do create the illusion that all patients will drive while impaired, or shoplift at local stores. Some patients are too sick or too unwilling to do well at an opioid treatment center. These centers owe it to their other patients and their community to refer patients doing poorly to other options.

Now for the number one most important factor that determines how well a patient will do while in treatment at an opioid treatment center…a warm and empathetic relationship with treatment center staff. This means all staff, not just their counselor. It includes the nurses and doctors and clerical staff.

It appears that behavioral change with addiction is more likely to occur when the people trying to help are caring and compassionate.

What an epiphany of the obvious.

Advertisements

9 responses to this post.

  1. Posted by Kerry Wolf on August 1, 2010 at 12:57 am

    Hi

    Great post, thanks!

    I do agree with you on most everything you stated. The only exception would be the one regarding patients not doing well in treatment. Though I completely understand why you said what you did, and you do indeed have a very valid point that “The reputation of opioid treatment centers is too important and too fragile” to continue to tolerate patients who may be continuing to use, methadone is first and foremost Harm Reduction. We know from experience that though MMT may mean recovery for many, for others it may be harm reduction–i.e., lessened use of IV drugs, less risky behaviors to obtain said drugs, and daily contact with medical and counseling personnel. Additionally, they have the chance to see other patients who ARE doing well, and to want this for themselves.

    Say, for example, that we have a patient who abuses opioids and cocaine. Through MMT he ceases to use IV opioids, but continues to use cocaine frequently. This is actually not surprising being that MT treats only opioid addiction, an to expect such a patient to simply stop using other drugs they may be addicted to without any treatment for that addiction whatsoever seems unreasonable–if they could “just stop”, they would have.

    It is excessively difficult and well nigh impossible for poly-addicted MMT patients to obtain treatment for their other addictions while remaining on MMT. The vast majority of inpatient facilities will not accept MMT patients unless they also want off methadone. There are at present only 2 or 3 such facilities in the country. This leaves these patients in a very difficult position.

    If we, then, remove them from treatment for displaying symptoms of the very disease we are treating them for, an when in fact that aspect if the disease (the cocaine addiction) has not even been addressed, we do them a great disservice. These patients will almost certainly relapse into opioid use immediately, and continue to abuse cocaine as well. They will no longer have daily access to medical personnel or counseling and referrals, nor the example of motivated peers.

    It seems indeed that the primary motive for removing such patients from treatment is the fear of what the public will think. While it is certainly true that the current atmosphere surrounding MMT is volatile indeed, this is due primarily to a lack of understanding by the general public of what MMT is about and how it works, and who MMT patients are. If people understood better the way that the brain chemistry is affected by opioid use, the permanent changes that occur in many brains, the fact that methadone does not treat other addictions, and the importance of not viewing methadone as a “reward” that good patients receive and bad patients are denied, but as a medication that treats a chemical disorder of the brain, the hostility and anger expressed by so many might begin to lessen.

    It’s a tough row to hoe–do we cave in to public pressure and kick out less than ideal patients, even though they are benefitting in some ways from treatment and wish to remain, with the goal of salvaging MMT’s reputation in the public eye and therefore ensuring that it remains available at all? Or, do we stand firm on the foundation of evidence based medicine and the Harm Reduction philosophy that ANY improvement and step forward is a worthwhile goal in and of itself, and meet the patient where they are, helping them to set and meet their OWN goals, not the goals we think they should have, and try our best to educate the public about MMT, knowing that there is a significant chance that we may lose MMT altogether or have it regulated so intensively that it remains out of reach for most patients?

    I don’t know the answer. Often, unpalatable compromises must be reached in order to make any gains at all. Nevertheless, I truly hate to think of patients being removed from treatment that is benefitting them simply because they have not recovered completely and don’t make good “shining examples” of what MMT can do. Certainly, AA does not toss out those who are still drinking in the name of looking good to the public.

    Again, thanks for a great blog post!

    Kerry Wolf

    Reply

    • Dear Kerry,
      Wow, thanks! You have eloquently stated some of the most difficult aspects of medication-assisted therapy. Often I yearn for an inpatient facility that will admit methadone patients, keep them on their methadone, and treat them for other addictions.

      Certainly cocaine causes problems, but at least it won’t kill you with methadone. I’m likely to hang in there with a patient who is trying to recover, and increase the “dose” of counseling. The biggest problem in my part of the world is co-occuring opioid and benzodiazepine addiction. It’s so hard to weigh the risk/benefit decisions. Our state has had too many overdose deaths, and many, possibly most, have been in methadone patients also addicted to or abusing benzos. I prefer to give a patient every chance if she has a willing spirit, but at some point I often decide that another form of treatment is better, and safer, though then we have to find a way the patient can afford it.

      One person’s harm reduction is another person’s enabling. Even I’m not consistent day to day with how I look at things. If there’s been a recent overdose, I’m more cautious for weeks afterward, hesitant to increase doses in patients positive for benzodiazepines. I think most of us do the best we can with the person in front of us, and try very hard to make the best decisions.

      thanks for writing.
      Jana

      Reply

    • Great post! I tried the methadone treatment and was successful in staying off Oxycontin while using the methadone. However, just as the first comment stated, I had other addictions. Specifically, I was using cocaine while using the methadone. I tested positive for cocaine 27 times before they finally kicked me out. It was a sudden decrease off the methadone which sent me right back to the Oxycontin. Although I was required to attending a group counseling session during my methadone treatment, I feel like they never actually treated my cocaine addiction. The methadone treatment centers would be of much more value if they could effectively treat all substance addictions. It’s still a great program in that it keeps addicts off the streets in regards to Opiate addiction. And, yes, it keeps them from using IV forms of opiates. But I think most opiate addicts also suffer from other substance addictions.

      Reply

      • Thank You!
        An excellent example of the question: “is the better treatment an obstacle to the best?” I certainly don’t have all the answers. But I agree with the statement of harm reduction proponents, “Dead addicts don’t recover.”
        thanks for writing

  2. In the state of Maine our Office of Substance Abuse made a clause in all of their grants that any treatment facility MUST accept methadone patients and CONTINUE THEIR TREATMENT. If they don’t follow this clause, they lose their grant money. This way someone on methadone can continue to treat their opiate addiction, but go inpatient for their illicit benzo or cocaine use-or even alcohol. This is true of all levels of treatment from IOP, to DETOX.

    Reply

  3. The other thing to remember is this story:

    A clinic director recently told me of a patient who had been in treatment for seven years, but had never been able to stop his cocaine use long enough to obtain takehomes. Because this clinic knew his chances of overdosing were astronomical and that relapse is part of the disease he was trying to treat-they continued to treat, monitor and counsel him.

    Last week they approved his first takehome dose after he had been able to remain cocaine abstinant for three months. A HUGE improvement in this persons life and proof that keeping him in treatment not only kept him alive long enough to reap the benefits of treatment, but also proved that no one is a lost cause.

    Thank you for the great blog post!

    Reply

  4. I go one’s a week and it’s sad that I dread to even go because I don’t know What to expect out of the stuff. I pay for their service but they act like they are doing me a favor! I m tired of being treated like a dog. Nd but its the truth..😟

    Reply

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s

%d bloggers like this: