My Favorite Patients are Drug Addicts

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Feeling exceptionally lazy again today, I decided to post a blog containing an article I wrote for the physician magazine Medical Economics. It was published in April of 2010, and I got some great feedback from other doctors. And since I’m a wannabe writer, I also submitted it to the annual Writers Digest writing competition in the magazine article category, and I won 8th place. I was over the moon about this, because this is a huge competition. I got a certificate which I framed and put on the top of my bookcase at home.

I’m prouder of this article than anything else I’ve written, because I was able to be heard by people in my profession.

Here it is:

When I was a fresh faced, newly unleashed graduate from my Internal Medicine residency twenty-three years ago, I never dreamed my favorite patients would be drug addicts.

In medical school, I learned little about drug and alcohol addiction and its treatment, and in residency, even less. I was well trained in the management of acute alcohol withdrawal, acute GI bleeding from alcoholic gastritis, and antibiotic coverage of endocarditis in an injection heroin user, but I couldn’t tell any of these patients how to find recovery from the actual underlying cause of their problems. I could only treat the sequellae, and I didn’t always do that with much grace.

The addicted person caused their own miseries, I thought, and since these were the Reagan years, they should “just say no” when offered drugs. My attitudes mirrored those of the attending physicians in my residency program. When an addict was admitted twice for endocarditis, needing an artificial valve the first admission, and its replacement on the second admission for re-infection, I was just as irritated as the attending and the rest of the house staff. I remember we discussed whether we could ethically refuse him treatment if he came in a third time! We were so self-righteous, though we had offered him little in the way of treatment for his disease of addiction. We might have had a social worker ask him if he wanted to go away for inpatient treatment, he said no, and that’s where our efforts ended.

I knew nothing about medication-assisted therapies for opioid addiction. Now I know better.

I was working part time in primary care when a colleague, the medical director at a local drug addiction treatment center, asked me if I could work for him at this center for a few days while he was out of town. He was a good friend so I agreed. I thought it would be easy money, and fun, doing admission histories and physicals on addicts entering the inpatient residential program, and I was right…but I also saw patients entering the clinic’s methadone program.

This appalled me. It seemed seedy, shady, and maybe a “fringe” area of medicine. It just seemed like a bad idea to give opioid addicts methadone. However, I had made a commitment to my friend, so I told myself I would work those few days, tell my friend politely when he returned that I didn’t “believe” in methadone (as if it were a unicorn or some other mythical beast) and could not work there again.

But when I talked to these patients they surprised and intrigued me. Some patients were intravenous heroin addicts, but most were addicted to pain pills, like OxyContin, various forms of hydrocodone, and morphine. Most of them had jobs and families, and expressed an overwhelming desire to be free from their addiction. I was most intrigued by how the patients talked about methadone treatment. They said such things as “It gave me my life back” and “Now I don’t think about using drugs all the time” and “Methadone saved my marriage and my life”.

Huh? With methadone, weren’t they still using drugs?

My curiosity piqued, I started reading everything I could find about methadone – and to my surprise discovered that the treatment of opioid addiction with methadone is one of the most evidence-based treatments used in medicine today, with forty years worth of solid data proving its efficacy. So why had I never heard of it? I could have referred many intravenous heroin addicts that I saw during my residency, which happened to be during the height of the spread of HIV, for effective treatment of their addiction. Because of methadone’s unique pharmacology, it blocks physical opioid withdrawal symptoms for greater than 24 hours in most patients, and also blocks the euphoria of illicit opioids. At the proper dose, patients should not be sedated or in withdrawal, and are able to function normally, working and driving without difficulty. Therefore, methadone maintenance is not “like giving whiskey to the alcoholic” as some ill informed people – like me – have accused.

For the next eight years I happily worked part time with my friend at this drug treatment center, and saw most methadone patients improve dramatically. Certainly methadone did not work for everyone, but it was a good treatment for many addicts. I did see some tough characters, but I was struck by how normal most of the patients seemed; most were not scary thugs as I had imagined, but housewives and construction workers.

Then I began hearing about a second medication to treat opioid addiction, called buprenorphine, better known by its brand name, Suboxone. The principle of this drug is the same as for methadone: it is a long-acting opioid, can be dosed once per day, and at the proper dose removes the physical withdrawal symptoms, and does not impair patients or give them a high. As an added bonus, it can be prescribed through a doctor’s office.
In 2000, the Drug Addiction Treatment Act allowed doctors, for the first time in about 80 years, to prescribe specifically approved schedule III, IV, or V controlled opioid for the purpose of treating people with opioid addiction. Shortly after this, the FDA approved buprenorphine for the treatment of opioid addiction, and the drug became available in 2003. In order to prescribe buprenorphine, a doctor must take an eight hour training course, petition the DEA for a special “X” number, and give notice to CSAT, the Center for Substance Abuse Treatment, of her intent to prescribe. Doctors prescribing buprenorphine also must have the ability to refer patients for the counseling that is so necessary for recovery from addiction.

Buprenorphine, a partial opioid agonist, is a milder opioid and there’s a ceiling on its opioid effects, making it a safer and better choice for many patients than methadone. It is particularly good for addicts with relatively short periods of addiction, and fairly stable lives. Since it is a milder opioid, it is relatively easier to taper, if appropriate.

I started prescribing buprenorphine from a private office and loved it from the first. Initially, Suboxone was expensive, but now generic forms have been approved, and prices have come down a little. Opioid treatment programs, formerly known as “methadone clinics” have started offering buprenorphine in addition to methadone.

The opioid addicts I met both in the opioid treatment program and in my private office have not been what I expected. The vast majority are ordinary, likeable people with jobs and families. They are your hairdresser, your grocery clerk, the guy that works on your furnace. They sit beside you at the movies and behind you at church. Because they have built a tolerance to the sedating effects of opioids, they do not look impaired or high; they are able to function normally in society…as long as they have a supply of opioids.

If they are in withdrawal, without a source for opioids, they will be sick. Some people compare opioid withdrawal to having the flu, but it is not. It is like having the flu…and then being hit by a truck. Most addicts in opioid withdrawal are unable to work because of the severe muscle aches, nausea, vomiting, and diarrhea. Many of these patients are blue collar workers with physically demanding jobs who initially used pain pills to mask their physical pain so that they can work harder, better, faster…never guessing that what seemed to be helping was actually causing them more harm than they could imagine.

Some patients seen in the office setting were professionals. Most professionals can afford the more expensive inpatient thirty- to ninety- day rehabs, a luxury for many of the working middle class. But I saw some lawyers, nurses, even policemen with opioid addiction who refused to consider inpatient treatment even if they could afford it. These professionals were concerned about their livelihood if it became public that they had a problem with addiction, or because they were unwilling to take time off work. They were willing to come to a doctor’s office where no one would know why they were being seen, and they did very well on buprenorphine.

I am thrilled when seeing a patient respond positively to treatment with buprenorphine. Many return on the second visit looking like younger and happier versions of themselves. On the second visit, a common phrase is “It’s a miracle!” Many patients say they just feel normal, even though they had forgotten what normal felt like. When an addict begins to recover, the changes are usually dramatic; they begin to smile, to restore relationships, to rejoin their families and their communities. When an addict recovers, the ripple effect extends throughout the community.

We know now that addiction is indeed a chronic disease much like asthma and diabetes. Just like these diseases, there are behavior components that can make the disease worse, and there are genetic and personal factors that put some people at higher risk. Sadly, many addicts are still treated with distain and disgust by their doctors, an attitude we would not tolerate towards any other disease. This causes patients to hide addiction from their doctors, and the disease worsens.

Many people, even doctors, still object to the use of medication assisted therapies for addicts, saying “it’s trading one drug for another”, when in reality it is trading active addiction for medication, when prescribed responsibly and appropriately. Drug-free recovery is ideal, but with opioid addiction, it does patients a disservice to dismiss the mountains of evidence proving the effectiveness of medication-assisted therapies with buprenorphine and methadone.

Detoxification alone (usually five to seven days) does not work, and shows relapse rates of up to 96%. If detoxification alone worked, the policy of imprisonment for addicts promulgated in the 1950’s would have solved the opioid addiction problem. It didn’t.

For most patients, their big question is: “How soon can I get off of this drug?” Most express a desire to be completely drug free at some point, but I think it’s important to get each patient involved in a recovery program before tapering their medication. This can be an intensive outpatient program at a treatment center, an individual therapist, or through 12-step recovery.

Some patients, particularly those with both opioid addiction and chronic pain, prefer to remain on buprenorphine or methadone indefinitely as the safest treatment for both problems, and these patients also seem to do very well.

As for me, I plan to continue treating addicts of all types. These patients have been among the most grateful that I have encountered in primary care, and show the most improvement. When I treat addicts and see peace return to a face that had been filled with shame, I get a unique feeling of accomplishment. These are events I am honored to witness.

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14 responses to this post.

  1. In your field of addiction- you are saving lives! It’s a lot more to helping an addict than putting a bandage on a scraped knee! You are truly saving lives! God will bless you for helping people that society has turned their backs on!!
    Thank you for all you do! Nacole

    Reply

  2. Posted by dbc901028 on August 17, 2013 at 4:07 pm

    Great article!

    As for the ‘mainstream’ view of addicts by doctors that you describe early in your career, even when we’re on Buprenorphine, we’re often treated like we’re still out there shooting up – or whatever they might think. Further, after stabilizing one’s life, leading a productive family life for years, it becomes more embarrassing for the patient than it was during active abuse or even shortly after recovery. I hate to even disclose anything that suggests I have a ‘seedy’ past, or am still on maintenance therapy – even though Buprenorphine doesn’t have the euphoria of full agonist opiods, those not ‘in the know’ see an opiod as an opiod.

    It’s a hard thing to deal with, as I feel it is important to be completely honest with medical doctors.. yet, if that honesty is going to cause me to be treated so differently, it makes it hard. I’m sure most doctors are professionals though, and do end up doing their jobs, no matter what their personal views. It’s the bedside manner that really ‘hurts’.

    The key thing, I think, to remember is that the price of addiction is high, and all sins are generally self-punishing. We don’t need other people to ‘pile on’. All addicts need compassion and pity. They certainly aren’t living the ‘high life’, and nobody wants to live like that. They are trapped by disease. And for those that have made it out, people should applaud their accomplishments, not put them down for their prior ‘weaknesses’.

    Reply

  3. Posted by Marvin Powers on September 2, 2013 at 12:19 pm

    I would like to express my Thanks to you on the article you have written. It shows to me how you were open to learning about addiction and methadone. I have been in treatment and on methadone since May 1983,I have had many experiences some good and some bad. I have had some wonderful counselors and Doctors.I have tried to detox on three different times without success and the last time July 2008 and ended up in the state hospital 3 different times it was not a good experience to say the least.I was put back on methadone and have remained. June,2011 I move to be closer to my family and I had to transfer to a new clinic. At the start I decreased 20 mg to transfer the Nurse at the new clinic said that they would only take me if I was on 150 mg or less so that was my reason I decreased. I have been there for 2 years and a few months and I have not seen any doctor until this past week and I requested to see the doctor for an increase in my dose. I know that the doctor is new to the clinic and has a private practice OB GYN. He graduated in 2009.I go in to the appointment with a very open mind to present my case. I started out with a little history of how long I have been in treatment and on methadone.I gave him a brief description of when my symptoms starts in the late evening and that i have only been sleeping on a good night 3 hours. I even mentioned that my family has noticed me having withdraws. His main thing was to get a P/T and then he would have to consult with another doctor and he kept saying that only if the P/T show that I need to be increased.He looked at me and said ” YOU ARE ONLY A REALLY REALLY HIGH DOSE”. I at that point asked if he was ASAM and he said no. Things were not going well and then tells me I will have to come in and face dose Monday ,Tues, Wed and Thursday I was upset from the point of him saying my dose was really high and I said that’s bullshit coming in all those days. I have never had a positive urine and have never missed an appointment and I have had my take homes since the 91 st day. My point being you trust me with take homes but don’t trust me to take my medicine daily and at the same time. I also phase up to level 6 with 13 take home on September 12.

    I need some help with how to handle this situation. So I don’t get my self into trouble. It just amazes me that he is writing for methadone but must consult another doctor with my P/T. It concerns me that he has no experience or it seems like.he would be more open. The stat of NC should mandate that doctors that treat addiction in clinic mush have some special training.The clinic I came from the doctor had all his certifications in addiction medicine and was also ASAM.

    PML47@aol.com

    Please help me Dr. Jana Burson

    Reply

    • Interesting comment at the very end, that NC should mandate doctors have some training to work at OTPs. There are people in NC who are coming to this same conclusion. For suboxone, a much safer medication, you have to take an 8 hour course to prescribe from an office setting.

      You aren’t going to like my answer about what your doctor said. I do think it’s standard practice to have the patient dose at the clinic for three or four days prior to the peak and trough. For me it’s a safety issue. There are patients, other wise doing well, who may be tempted to take less of their usual medication in order to have a lower peak/trough level. They do this out of fear, of not getting enough medication. But if they do this they could end up getting dose increases when they don’t really need them. So yes, I ask patients on levels to dose with us for the three or four days prior to getting blood for peak and trough.

      You probably know that if the peak is more than twice the trough, your program may want to split your dose. If you’re a fast metabolizer this could help you, so I do recommend you go along with what your doctor is recommending.
      More and more I realize there’s a big difference in how people metabolize methadone. You may have the same blood level taking 150mg as another person does taking 55mg. There’s that much difference. As it turns out, 150mg may be higher than many people take, but it may not be enough for you.

      I think you’re more likely to get what you want if you remain polite, yet firmly advocate for yourself. You could ask your doctor to read, or at least have on hand for a reference, TIP 43 published by SAMHSA. That’s a free publication for anyone interesting in methadone at the OTP. Get yourself one & your doc one as a gift. (Though I’d be appalled if he didn’t already have one & read it cover to cover):

      http://store.samhsa.gov/product/TIP-43-Medication-Assisted-Treatment-for-Opioid-Addiction-in-Opioid-Treatment-Programs/SMA12-4214

      Reply

      • Posted by marvin on September 2, 2013 at 6:25 pm

        I would like to again say Thanks for your time and energy to reply so quickly to my Questions. I don’t dislike your reply it all is coming together and that is why sometimes for me if I can get answers from another source it seems to bring light to the situation and it did.
        I just still have some concern about his decisions if he is not listening to the patient and needs to consult with another Physician with my P/T before he will be able to increase my medication. The comment he made about my really high dose at 150 mg just somehow touched a nerve and I reacted and from experience I Know that this is not the best thing. He made me very aware that for me to remember he writes the order for increases.

        I will be patient and do what is required to do the P/T and wait for the results and go from there its really the only option I have. I do have the TIP 43 Booklet and have an extra copy that I will offer him and hope that he will not think that I am being a smart. There are so much information about not making it a numbers thing and listen to the Patient. .

        Dr. Dole stated in many of his articles that there isn’t a low or high dose but a adequate dose. I also like what you have said about what is the right dose and you said “enough”.

        Thanks
        Mark

      • If there is a question as to whether the patient is taking the medication properly and such a “safety issue” is even a concern… Then why are takehomes being given in the first place? The act of allowing a patient to have takehome doses of medication is itself saying that a treatment program/provider trusts the patient is taking each & every dose properly. So, again, why require a patient to be burdened dosing in-house leading up to a medical test if they have takehomes? If there is ANY concern a patient isn’t taking their medication as dispensed/instructed then the treatment program/provider shouldn’t be giving them takehomes in the first place! Requiring a patient to present daily for medicating leading up to a Peak & Trough Test on days their current phase level/takehome schedule normally wouldn’t require them be present at the clinic seems like an ENORMOUS contradiction to me. The fact the patient HAS takehomes says the program/provider trusts they are being taken correctly. Why would this change the few days leading up to a blood test? That appears to be an admission that the program/provider doesn’t “trust” the patient is/will taking/take their medication as dispensed/instructed… in which case, once again, they shouldn’t have been given takehome doses in the first place! (I’ll stop talking in circles now, but this appears to be a huge contradiction and undue burden on the patient. There is nothing in federal or NC state regulations that require such a hardship on a patient.)

        Because treatment works,
        Zac Talbott
        NAMA-R TN
        http://www.methadone.org

      • Sorry you see it as a contradiction. I see it as a safety measure.
        I have patients come in for observed dosing before P&T because I’ve had more than one patient tell me (much later) that they have skipped take home doses prior to a P&T in order to make their levels appear lower, in order to be granted a dose increase. I do think they did this out of fear, that they wouldn’t get an increase they needed. I think such fears arise even in patients with time of stability.

      • I think in that light you have a valid concern. And it’s not necessarily that these patients are “scheming” or trying to obtain dose increases they don’t need – – so much as they are scared the test results will somehow deny them NEEDED increases? I can certainly see where you’re coming from. But, even still, to have “blanket policies” that apply to all patients goes against the individualized treatment that we know works best, don’t you think? Allowing “exceptions” to this rule if it is a stable patient who travels more than 100 miles one way to the program – or a patient whose work schedule simply won’t allow them to go back to daily attendance, even just for 3 days – or other situations that truly make requiring daily attendance an undue hardship is something I hope programs with these “in-house dosing requirements” for blood tests will consider.

        I also think that many patients understand that the science behind Peak & Trough Tests are shaky (At best) in determining the need for an increase. With American methadone having both active & inactive isomers, and the test not being able to distinguish between the two, the numbers alone from a P&T don’t show the need for an increase on their own. The numbers could be 75% inactive isomers, or (on the other hand) could be 75% active isomers, but the point is we just don’t know. P&T Tests are certainly better at indicating the need for a split dose (since metabolism is the same whether the isomers are active or inactive), but for determining dose increases? Perhaps if it is ONE factor that is considered along side other things with the MOST importance being given to patient testimony P&T could be useful as one indicator for the need for an increase… But it would be medically unethical to say the least – and absent sound medical science – to arbitrarily deny a needed increase based on P&T Test results *alone.* However, that has been done many times to many patients… Patients who truly DO need the increases are being denied because of numbers from P&T Tests in some instances. We’ve successfully gotten many clinics to stop using P&T Tests all together for dose level determination (they still employ them in determining the need for split doses)… The science simply doesn’t allow those tests to be medically-sound or scientifically-accurate indicators of the true level of active methadone in a patient’s blood. And because many patients know the SCIENCE behind the tests they fear that they will have results that don’t reflect the reality of their dosage needs & (because of unethical and science-less practices by some programs) feel forced into “manipulating” these already inaccurate tests if there is a fear the results will be arbitrarily used to deny the increase without giving weight to their account. Dr. Dole always said at the conferences when people would be so OBSESSED with “How do we know if they REALLY need an increase?” and “How can we tell if they’re asking for an increase for legitimate reasons?” And Dr. Dole’s answer was always quite simple: “ASK the patient,” he would say. Nothing is a better indicator than that.

        Thank you again for your efforts & for being willing to engage in dialogue, but unfortunately many programs and providers don’t espouse your passion and knowledge & use things like P&T Tests as a means of denying needed increases without even understanding the science behind the tests… Or, in the case of TN, the state can use these test as a means of unofficially (since it’s illegal) “dose capping” without calling it such…..

        Anyway, I certainly think you have valid concerns, but none of ANY of our concerns should trump the prioritizing of individualized and individually-tailored treatment… including the need for in-house dosing leading up to a blood test.

        Because treatment works,
        Zac Talbott
        NAMA-R TN
        http://www.methadone.org

      • You raise some really excellent points.

        I do have some patients who don’t need to dose with us every day before a P&T. Then the problem becomes that other patients feel we are being unfair, because we treat them differently. I understand what they are feeling – I’m sure I’d feel the same way – but as you point out, care should be individualized. So I struggle with the decisions.

        I only get a P&T when I’m considering a split dose. If the patient is too unstable for split dosing – like chaotic home life – might as well not even get them…unless the clinic happens to be open long enough to split dose on-site.

        I know about the methadone enantiomers, but the studies on blood levels, peak and trough etc. have been done with the racemic methadone, so I do think the literature applies. If we used European methadone preparations I’m sure patients’ doses would be lower, since it’s all the “D” form. (Or is it the “L” form? I forget)

        This will be controversial to methadone treatment advocates: some patients want dose increases because the disease of addiction tells them “more is better,” and not because they are feeling withdrawal. So no, patient request for increase alone is not sufficient reason to go ever upwards on the dose. (But if they are on a relatively low dose, like less than 120mg or so, I assume they are still in withdrawal)

        I know it’s not politically correct to talk about that, but it’s real. We are dealing with a disease that tells the patient that excess is not enough. Some patients like the feeling of increased energy or opioid feeling they get right after a dose increase, and we know tolerance to that feeling develops quickly. They end up chasing a sensation that won’t last, no matter how high the dose. Part of my job is to educate patients about this, and explain that if they are at a dose that relieves their withdrawal for the whole 24 hours, more medication probably won’t help.

        With a patient who requests a dose increase but can’t tell me any withdrawal symptoms, if my clinical impression is that the patient does not need a dose increase, by both history and physical exam, I sometimes get a trough level. If I get back a low-ish level, I’ll change my mind and try dose increases. If the level is very high, it confirms my clinical impression. Mid-level results aren’t very helpful. Trough level can be one piece of the pie of the decision-making process.

        I agree that in many clinics, blood levels are given too much weight. Like they say in med school, “Treat the patient, not the lab.”

      • I am so thankful to read that you don’t implement (or at least don’t enforce) “blanket policies” when it comes to your patients’ medical treatment. I also understand why some patients might be upset if they were required to dose in-house the days leading up to a Peak & Trough Test and knew that another patient was not. However, THIS is where *patient responsibility* comes in, in my opinion. If patients truly want individualized treatment – which has been repeatedly shown to be the best approach – then we also have to make decisions that encourage an atmosphere conducive to a patient by patient approach. Most patients are well aware of the things in which their individual treatment may vary, and it’s sometimes best to simply *keep it to yourself* when it comes to the specifics of what may and may not be required of you within the realm of things where treatment providers have room for variance based on their individual judgment. In other words, if I was a patient at your program and my individual situation was such that you determined I did not have to report for in-house/”window” medicating the several days leading up to a blood draw for a Peak & Trough Test then chances are I am going to KNOW that many patients DO have to report daily leading up to the blood draw, so (to protect my own individualized treatment by encouraging an atmosphere that is NOT confrontational or “dramatic” so that my treatment provider will continue being willing to look at my treatment individually – and out of respect & a show of “thanks” to my treatment provider for treating me based on my individual situation) it is in MY best interest (and the best interest of all of my fellow patients) to just, quite simply, KEEP MY FRICKIN’ MOUTH SHUT & not tell other patients, “Guess what? Dr. Burson isn’t making me come in every day; I get to just take my medication as usual and come in and have the blood draw on my normal day for clinic attendance,” because that accomplishes NOTHING and, if anything, is COUNTERproductive because it has the potential to cause confrontation & require my physician to address unnecessary drama, wasting time that would be better spent on the individualized treatment of her patients! (Not to mention that the doctor might be less inclined to look at my individual situation in the future because of my “big mouth” causing problems!)…. So I very much think that patients play an important role, by their decisions, actions & words, in determining to what extent they are able to receive (or their treating physician is willing to offer) individualized treatment.

        I also agree that *some* patients (and if I were simply guessing based on my interaction with numerous patients at numerous clinics in numerous states on numerous doses with varying lengths of time in treatment over my years in advocacy, in addition to my own personal experiences as a MAT patient myself) will try to obtain dose increases for the “wrong reasons.” I also very much agree (as I think I would have to if I profess to believe in science) that such increase requests absent a legitimate medical need are often simply the reality of the characteristics and manifestations of the psychological components of the disease that is being treated. I also certainly do not think that a patient’s request for an increase *alone* should universally result in an increase being granted. I am sorry if that was the impression I gave. Please allow me this longer-than-usual post to clarify because I think this is important. When I refer to patient testimony & asking the patient as the best way to *determine* the need for a dose adjustment or if the patient is stable I was not referring to a situation like this:
        PATIENT: “I need an increase. My dose isn’t enough.”
        DR. BURSON: “If you say so! Would you like to go up by 5mg or 10mg today?”
        No, no no…… (Well, perhaps on the traditionally “lower” doses earlier in treatment something more similar to that might be ok in some instances, but I am referring to the “higher” doses at which Peak & Trough Testing would be a factor. It is usually when patients are on doses greater than 120mg’s, if not 150mg’s, that Peak & Trough Testing starts coming into play at programs that employ their use.)… When I refer to patient testimony and asking the patient being the best way to *determine* the need for a dose adjustment or if the patient is stable, the key word still remains **DETERMINE.** I still very much think that the physician, nurse practitioner or physician’s assistant must ultimately rely on their medical judgment to *determine* the need for an increase or adjustment. I simply meant that patient testimony in regards to withdrawal symptoms, cravings, whether or not they feel illicit opioids if they are not yet free from illicit substances, etc. is the most accurate and reliable way to **determine** if an adjustment is warranted. If a patient can not tell you any physical withdrawal symptoms and/or verbalize or explain what they are feeling or what is going on that causes them to feel as though they need an adjustment then, knowing the individual patient’s situation, history, personality, ability to communicate, record of compliance, etc., the clinician is going to have to consider all of that to *determine* if an adjustment is warranted in their medical opinion. The “patient testimony” and “ask the patient” I frequently mention is referring to patient testimony as to WHY an adjustment is needed and WHAT they are experiencing and HOW they are feeling… I was *NOT* referring to “patient testimony” as simply a patient saying, “I need a dose increase!” and then, because they patient said they need it, arbitrarily giving it to them no matter what. That is *NOT* at all what I was referring to when I talk about “asking the patient” and “patient testimony” being the best indicator and factor to consider when a treatment clinician considers the situation and weighs all of the facts and circumstances when **determining** if there is a need for a dose evaluation/adjustment in their medical opinion. I hope that makes sense and that I have been more clear about what exactly it is that I am advocating for when I encourage treatment providers to “ask the patient” and give the most weight to “patient testimony” when determining the need for a dose adjustment.

        THAT being said, however, I am extremely comfortable with saying absent any official source citation other than the experience and real-life learning as an advocate and patient I mentioned earlier that the MAJORITY of patients do *NOT* continue to ask for increases beyond stability. It’s super important, in my opinion, that we don’t put the majority of patients through extra steps, tests, processes and other “exercises” that are only potentially necessary for the small minority of patients who, for whatever reason (but often largely due to a poor understanding of the pharmacology of methadone itself), might continue to seek increases beyond the dosage that they require for adequate and stable medical maintenance treatment. Too often treatment centers/clinics (typically the ones that have a larger patient census and/or belong to huge nationwide corporate conglomerates) have implemented extremely burdensome, overly-punitive “policies” and “protocols” in the hopes of addressing or rectifying certain issues of non-compliance in which only a small minority of patients engage and, as a result, place an undue burden and unnecessary frustration on the entire patient populous. Those things are the opposite of the recommended “individualized treatment” we’ve mentioned throughout the last several comments. So just how big of a deal/risk is the possibility that a minority of patients might ask for an increase they don’t truly need? I can’t help but think that the risk is EXTREMELY small (if not completely non-existent). The largest increase/amount of methadone that can be given at one time in addiction treatment within a 24 hour period after the 1st day of treatment is 10mg. Some programs routinely give 5mg increases more frequently than 10mg increases (which I think is just silly in many circumstances). An opioid dependent person that is methadone-tolerant and already on a daily, regular, maintenance dose of methadone – quite simply – pretty much CAN NOT overdose on methadone. If my normal dose was, say, 160mgs/day and I have been on that maintenance dose (or even a maintenance dose of a smaller amount like 55mgs/day) for at least a few weeks or months then it is virtually IMPOSSIBLE to overdose on methadone. (I say “virtually” but know many MAT medical experts and seasoned MAT advocates who say it IS impossible for an opioid dependent person that is methadone-tolerant to overdose on methadone.) I could take an addition 600mgs of methadone on TOP of my normal daily dose of 160mgs – or 55mgs – or whatever my dose might be and be just fine! I’d likely get some REALLY good sleep that night & most people would probably feel really tired and some may appear drowsy, but there would not be any serious medical risk of overdose. (I am speaking *specifically* and *only* about people who are already methadone-tolerant and maintained on methadone daily being highly unlikely to overdose on methadone *ALONE* – Of course if other substances or sedatives like alprazolam, soma, clonazepam, whiskey, valium, etc. are consumed/ingested in addition to methadone then the risk of overdose and/or death is extremely real & extremely high!) So why am I saying all this?? (It’s certainly NOT to say it’s “OK to take extra methadone”… it would likely just waste another day’s dose anyway!) My reason for bringing ALL this up and writing this novel of a comment was to say THIS after having provided some of the basic background for the statement to be understood: The “risks” that may result if ANY methadone-tolerant patient receives an additional 10mgs (max increase allowed) that they really “don’t need” practically are non-existent. Why would we potentially “grill,” question intensely & possibly even deny an increase to a patient who truly DOES have a legitimate medical need for a higher dose (and I am confident that the majority of patients who seek a dose increase have legitimate reasons for asking) in the hopes of maybe “catching” one of the small minority of patients who might ask for an increase they don’t truly need, especially when there is NO additional euphoria, “buzz” or “high” experienced by the vast, vast majority of patients from an increase as small as 10mg or less AND there is virtually NO risk of medical complications or overdose from such a small increase in dosage regardless of whether an increase is or is not truly warranted? While I do think that many times good intentions are at the core for many providers, are the small minority & few cases of occasional patients who may request an increase they don’t truly need (when the additional 10mgs or less poses no significant risk of medical complications or overdose/death) worth putting the vast majority of patients who DO have a legitimate reason for requesting an increase through additional stress, questioning and/or potentially even denying a dose increase to a patient who truly needs it?

        I am so sorry for such a loooong post, but I think it was important to clear up a couple things that I must have unintentionally insinuated and it was also necessary to be extremely clear about a couple points I was making that were necessary for me to be able to ask the question(s) to which I am curious of the answer(s) from a provider’s perspective.

        I appreciate the dialogue, and I think others may very well be able to benefit and/or learn from our discussion. These are things and ideas that have been pondered and “thrown around” by several different folks in the national MAT community over time, so it will be helpful & interesting to gain your perspective. I hope I didn’t confuse!

        Regards,
        Zac Talbott
        NAMA-R TN

      • Thanks Zac, excellent points.

      • And Tennessee…don’t get me started. With that dose cap, those state administrators have put themselves into the situation of practicing medicine without a license. If someone has a bad outcome because of a denied increase, I believe they should bear the responsibility.

      • You’re exactly right, Dr. Burson. It is unconscionable just exactly what is going on at the State level in Tennessee when it comes to the medical treatment of opioid addiction with medicine in Opioid Treatment Programs (OTPs) in our state. Luckily our Tennessee OTPs are *finally* organizing into a State Chapter of AATOD, and with the way things currently stand it looks like the TN Chapter of AATOD will be official and announced in November. (I am assuming the goal is to announce it at the AATOD Conference in Philadelphia, most likely during/immediately preceding the Open Board Meeting of AATOD Saturday evening before the official conference sessions begin.) I’m flying into Philly Friday afternoon/evening Nov. 8th and then doing Pre-conference sessions on Saturday & Sunday and staying through Wednesday. I’d actually really like to do the “clinic tours” that are always the last thing of the last day… I just think that would be really neat and interesting to see how large inner-city OTPs might operate compared to the more “rural” OTPs I work with on a regular basis in Tennessee and Northwestern Georgia. (Sorry that is TOTALLY off subject – I am pumped up about the conference… Are you going?)

        The State of Tennessee is violating federal law in a few way…

        – As you mentioned, they are practicing medicine without a license.
        – Interfering with and manipulating the medical treatment of a chronic disabling disorder protected by the Americans with Disabilities Act (ADA)
        -Further violating federal law by discriminating against a “protected class” (class = opioid dependent TN residents/citizens) – which is the main focus of the DOJ’s current investigation into the state. All the media hype seems focused on Johnson City, but the reality is that the DOJ is in no way restrained. They typically identify ALL who contribute to the discrimination, and that would certainly include the State.
        – Preventing and actively obstructing people with active, untreated substance use disorders from seeking the most effective and evidence-based medical treatment available for their disease in violation of the Rehabilitation Act of 1973 (not sure on year?)
        ….and a few other things I can’t think of off the top of my head….

        And you’re ABSOLUTELY right that the State is setting themselves up to be heavily responsible and LIABLE due to their interference with medical treatment AND – the craziest part to me – The state of TN is committing malpractice WHILE practicing medicine without a license! Ha. ONLY in TN and ONLY when it comes to MAT…. But I have hope, I have to. Thanks for your continued support for those lucky few who are receiving (often inadequate) treatment in TN and the many more who are afflicted by opioid addiction for who treatment is just simply not available or accessible.

        Holding onto hope,
        Zac Talbott
        NAMA-R TN
        tndirector@methadone.org

  4. @Jana thank you for lending your hand, time, and effort as to helping those individuals who have lost their faith to humanity, people who are trapped and has chosen the path towards drug addiction, I was wondering if you’re working in some drug rehabilitation centers? Like Care Treatment Addiction Rehab just curious.

    Reply

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