I spend much time and effort explaining how medication-assisted treatment for opioid addiction works for many addicts. It occurred to me that I should explain who isn’t a good candidate for such treatment.
I enthusiastically support medication-assisted treatment (MAT) of opioid addiction, but no treatment works for everyone. MAT doesn’t work for every opioid addict. Here are some reasons a patient may not be suitable for MAT:
1. The patient isn’t addicted to opioids. That seems obvious, but occasionally I encounter an addict who wants to be started on methadone even though he’s not addicted to opioids. Rarely, an addict using cocaine, benzodiazepines or other drugs will come to the OTP after they have heard how well it worked for other (opioid) addicts. After I explain that buprenorphine (Suboxone) and methadone only work on opioid addiction, some of these patients have become angry.
One patient accused me of discriminating against her because of the type of drug she used. I said yes, but only because methadone doesn’t treat cocaine addiction. (I tried to refer her for more appropriate treatment.)
2. The patient takes opioids for pain, but has never developed the disease of addiction.
Such a patient may be physically dependent, but lacks the hallmark indicators of addiction, such as misuse of medication, obsession and compulsion regarding opioids.
Opioid treatment programs, (OTPs) have stringent regulations put on them by both federal and state government, because OTPs are designed to treat patients with addiction. These patients have lost the ability to control their intake of opioids, so the OTP regulates a maintenance dose of either methadone or buprenorphine to keep the patient out of withdrawal and able to function normally.
If a patient has only pain and no addiction, there’s no reason to enroll in an opioid treatment program, because patients without addiction are still able to take opioid medication as prescribed. Pain medication can be prescribed by any doctor with a DEA license.
Opioid treatment programs aren’t intended to treat chronic pain, but if a patient with both addiction and chronic pain finds methadone also helps with pain, it’s a nice benefit. Many of these patients do find they have less pain once they’re out of the miserable cycle of intoxication and withdrawal. So less pain is a happy side effect of addiction treatment.
3. The opioid addict presenting for treatment has been physically dependent for less than one year.
Methadone is difficult to get off of, and federal and state regulations say it cannot be prescribed for opioid addicts with less than one year of addiction (daily use or near daily use). This is a somewhat arbitrary cut off, and the OTP physician can ask for an exception to this regulation if needed. Even if the OTP wants to treat the patient with buprenorphine (Suboxone), which is usually much easier to taper off of than methadone, permission must be sought from state and federal authorities before enrolling a patient who has used opioids less than one year.
If buprenorphine is prescribed in the office setting, the prescribing physician can use her best judgment about who is appropriate for treatment, without needing government approval.
4. The opioid addict has the ability to go to a prolonged inpatient residential treatment program for his addiction.
This is controversial, because some doctors think medication-assisted treatment should be given to everyone because of its success rate compared to abstinence-only treatments.
But who gets the best of medical treatment in our country? Possibly it is medical professionals like doctors and dentists, airline pilots, politicians, and celebrities. They usually get the gold standard of treatment for whatever disease ails them.
If such people have opioid addiction, they are treated with inpatient medical detox, using buprenorphine to ease withdrawal, followed immediately with prolonged inpatient residential drug addiction treatment. I know doctors and dentists who spent six to nine months in treatment. After treatment, they must sign monitoring contracts with their licensing boards in able to go back to work. These contracts usually involve a mandated number of group sessions per week and random drug testing. With this kind of support and accountability, these medical professionals have excellent outcomes. Studies show that more than 80% are still off all drugs and alcohol at five years after entering treatment.
If only everyone could get that kind of treatment!
If this kind of treatment is available to the addict…take advantage of it. But most opioid addicts can’t access this kind of treatment, with post-treatment accountability. Insurance companies might pay for a one-week stay in detox, which won’t help. Even if the addict gets a few weeks of inpatient treatment, it’s usually not enough. What I’m talking about is months of quality inpatient treatment.
5. An opioid addict who is also physically addicted to alcohol, benzodiazepines or other sedatives. These drugs can be deadly when mixed with methadone or buprenorphine. I prefer such patients enter a medical detox unit to get off these sedatives prior to entering treatment in an OTP.
Of course this is a complex issue, and there may be times when starting methadone or buprenorphine can be done, perhaps keeping the patient at a relatively low dose, while the patient undergoes a gradual taper from benzos. The OTP physician should be free to use her best judgment about how to treat these complex and high-risk patients.
6. The opioid addict also has acute, severe mental illness. An actively suicidal patient is too sick for an outpatient opioid treatment program. So is an acutely psychotic patient who is having hallucinations and delusions. These patients often can’t to understand what is real and what isn’t. Ideally these patients need inpatient treatment at a facility that will treat both mental illness and addiction. Sadly, it’s getting ever harder to find such facilities for patients who need them.
7. A patient has behavior that interferes with treatment.
OTPs have an obligation to all their patients to maintain a safe and orderly treatment environment. Patients who start physical fights, threaten staff or other patients, or sell drugs shouldn’t be kept in treatment. I know that sounds harsh, but OTPs have a hard enough time maintaining good standing in their communities without having to face accusations about illegal behavior on premises.
Patients need to be emotionally stable enough to conduct themselves in a non-threatening manner to be able to remain in treatment. Some patients, after being counseled about acceptable behavior, are able to comply with requests for behavioral changes. Some patients have erratic behavior due to mental illness, and shouldn’t be blamed, but their behavior still may be too disruptive for the OTP setting.
8. The patient has serious co-existing physical health problems.
Actually, I can’t think of any physical health problem that would make the treatment of opioid addiction with methadone riskier to the patient than untreated opioid addiction. We know for sure that untreated opioid addiction produces high risk of death and disability.
Issues like severe lung disease and specific heart rhythm problems do increase the risk of medication-assisted treatment, especially with methadone. I try to contact the patient’s other doctors and consult with them before the patient goes above a low dose of methadone.
Ideally, I’d like to talk to the other doctors on the day of admission, before methadone is started, but that can’t always be done. With the time pressures doctors are under, it’s getting ever harder to claim some of their time for a patient consultation.
Some of these patients could be started on buprenorphine instead of methadone, which is safer with these health conditions, and has fewer medication interactions.
9. The patient has transportation difficulties.
Some patients can’t get a ride to their treatment program every day, which interferes with delivery of quality treatment. With buprenorphine, federal requirements for daily dosing were lifted, but states still have varying regulations. With methadone, the patient must come for treatment daily. During the first two weeks of stabilization, it’s important for medical personnel to be able to evaluate the patient every day, to assess the effects of dose increases.
10. A patient who enters treatment expecting to be completely drug free in the near future.
I try to make sure patients entering treatment with methadone or buprenorphine understand that I am not switching them from illicit opioids to these medications because tapering off of them is easier. Particularly with methadone, it is not. But both methadone and buprenorphine are so long-acting, they can be dosed once per day, giving the patient a steady level of opioids. This allows the addict to function normally, without withdrawal or impairment, once the dose has stabilized.
Both medications give the opioid addict time to regain physical and mental health. Once on a stable dose, the recovering addict can make changes in his life, with the help of counselors and other OTP workers. The addict can get back to work, stop a life of crime, form better relationships with his family and himself, and recover a better quality of life.
Will that addict ever do well off methadone? There’s no way to be sure about this. Some patients can taper off methadone, as long as they address all of their issues prior to the taper, and if they bring the dose down slowly enough that they don’t feel intolerable withdrawal. Some, perhaps most, recovering addicts find they will do better if they stay on methadone.
All this is to say that the goal of entering an opioid treatment program isn’t necessarily to
get off the treatment medication.
So if a patient seeks to enter methadone treatment but also expresses a desire to be off buprenorphine or methadone within weeks to months, I tell them their expectations aren’t realistic. These medications don’t work like that. If the patient wants to get off all medications quickly, they need referral to an inpatient program. This way, patients can’t later say they were mislead, and they feel like they have liquid handcuffs, chained forever to methadone, with its many regulations for treatment.