Who Should NOT Be in Medication-Assisted Therapy with Methadone or Buprenorphine?

Liquid methadone

 

 

I spend much time and effort explaining how medication-assisted treatment for opioid use disorder works for many people. It occurred to me that I should explain who isn’t a good candidate for such treatment.

I enthusiastically support medication-assisted treatment (MAT) for opioid use disorder, but no treatment works for everyone. Some patients may be too ill for this form of treatment and some may not be ill enough, and find other treatments that work for them. Here are some reasons a patient may not be suitable for MAT:

The patient doesn’t have opioid use disorder. That seems obvious, but occasionally I encounter an addict who wants to be started on methadone even though he’s not using opioids. Rarely, people using cocaine, benzodiazepines or other drugs will come to the OTP after they have heard how well it worked for other people, who do have opioid use disorder. After I explain that buprenorphine (Suboxone) and methadone only work for opioids, some of these patients have become angry.

A few weeks ago, a woman came to our opioid treatment program who hadn’t used opioids for nine months, and – by her history – never had an obsession or compulsion to use them in destructive ways. When I explained to her why our treatment wasn’t appropriate for her, she became angry, and said it was her right to get treatment because of the CURES grant.

This made no sense to me, and I tried to explain myself several times, but she left, angry she was being denied a treatment that the government was paying for, because she felt that meant she was entitled to the medication if she wanted it.

The patient takes opioids for pain, but has never developed opioid use disorder.

Such a patient may be physically dependent, but lacks behaviors that indicate loss of control over opioids. The patient denies any misuse of medication, or obsession and compulsion to continue using opioids despite adverse consequences.

Opioid treatment programs (OTPs) have stringent regulations put on them by both federal and state governments. OTPs are designed to treat patients with opioid use disorder; these are patients who 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 opioid use disorder, 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.

While opioid treatment programs aren’t set up to treat chronic pain, many of our patients with both opioid use disorder and chronic pain find methadone and buprenorphine helps with pain. That’s a nice benefit. Many of these patients feel less pain once they’re out of the miserable cycle of intoxication and withdrawal. So less pain is a happy side effect of our treatment.

Having said this, there are those unfortunate patients who have been dismissed from pain clinics for reasons other than misuse of opioids. They don’t meet criteria for opioid use disorder, but they are clearly physically dependent on opioids and can’t find timely treatment. I have – at times – admitted these patients, under an exception filed with SAMHSA, with the understanding that they would be better served by eventually transferring to another pain management program.

The patient with opioid use disorder asking for maintenance treatment has been physically dependent for less than one year.

Methadone is difficult to taper off of, and federal and state regulations say it cannot be prescribed for people with opioid use disorder with less than one year of physical dependence. This is a somewhat arbitrary cut off, and the OTP physician can ask for an exception to this regulation if she feels it’s in the best interest of the patient.

Even if the OTP wants to treat the patient with maintenance 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.

This doesn’t apply to office-based buprenorphine practices, who don’t have to follow federal and state regulations for opioid treatment programs. 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.

To further confuse this issue, patients who have been on MAT in the past may be re-admitted onto MAT even without a year of physical dependence, if that patient thinks that relapse back into active opioid use disorder is imminent. Also, pregnant patients with opioid use disorder don’t have to meet the one-year requirement because of the benefits to both mom and baby with MAT.

The person with opioid use disorder can go to a prolonged inpatient residential treatment program.

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 use disorder, they are often 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 people with opioid use disorder can’t access this kind of treatment, with extensive post-treatment counseling, monitoring, and accountability.

A person with opioid use disorder 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. However, it’s a complicated problem, and the admitting physician needs to make a judgment about the risks of starting treatment while the patient is physically dependent on sedating medications, compared to the risks of delaying treatment for the opioid use disorder.

The FDA issued a statement in 2017 saying that “the opioid addiction medications buprenorphine and methadone should not be withheld from patients taking benzodiazepines or other drugs that depress the central nervous system…” They issued this statement after releasing the black box warning in 2016, saying opioids combined with benzodiazepines or other sedatives was dangerous and could result in death.

I believe this more recent statement was their way of indicating the risks may be outweighed by the benefits for patients contemplating admission to treatment for opioid use disorders with MAT. After all, patients with active opioid use disorder can die.

The person with opioid use disorder 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 opioid use disorder. Sadly, it’s getting ever harder to find such facilities for patients who need them.

Some patients may have neurologic dysfunctions that impair their ability to understand and consent to treatment. Such patients usually have people authorized to make decisions for them, and we must bring that person into the discussion and get consent to treat from them.

If a patient has some sort of temporary condition that impairs their ability to understand and consent to treatment, we may ask them to return on another day. For example, we sometimes have a new patient present for intake who is impaired to the point where consent is impossible. We make sure a responsible party can drive them home, and make plans for them to return the next day.

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.

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 use disorder with methadone riskier to the patient than untreated opioid use disorder. We know for sure that untreated opioid use disorder produces high risks 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 patient’s 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.

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. Most opioid treatment programs are open seven days a week for dosing.

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 person with opioid use disorder time to regain physical and mental health. Once on a stable dose, the recovering person can make changes in his life, with the help of counselors and other OTP workers. He can get back to work, any criminal activity, form better relationships with his family and himself, and recover a better quality of life.

Will that person ever do well off methadone? There’s no way to know. Some patients can taper off methadone, if they bring the dose down slowly enough that they don’t feel intolerable withdrawal. Some, perhaps most, recovering people 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.

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. I try to explain these medications don’t work like that. If the patient wants to get off all medications quickly, I can give referrals to programs that can help them. This way, patients can’t later say they were misled, and feel like they have liquid handcuffs, chained forever to methadone, with its many regulations for treatment.

I hope this gives a little guidance as to which patients are most appropriate for medication-assisted treatment.

 

 

 

 

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6 responses to this post.

  1. Posted by Greg on July 31, 2018 at 4:17 am

    Excellent post and so easy to understand,I so wish we had more drs like yourself that care about us addicts and don’t look down on us,thanks for all you do

    Reply

  2. Posted by Alan Wartenberg MD on July 31, 2018 at 6:37 pm

    I would list one more group, but it’s a group we do not see often, which will be immediately apparent – the patient with strong moral and/or spiritual/religious objections to agonist therapy. These may be individuals who have spent considerable amounts of time in 12-step programs in the past, or have very strongly held beliefs that one is “substituting one addiction for another.” I always spent time if such individuals got into my office, sometimes through well-meaning parole/probation officers, doctors or family members/friends. If I could get through with my case, some were appropriate and willing to start agonist therapies. But many if not most were there against their will and really did not want to start agonist treatment. However, as with individuals entering long-term residential treatment, I think the use of either oral or injectable antagonist treatment (naltrexone tablets or Vivitrol® – extended release injectable methadone) is not appropriate, but is becoming the standard of care if agonist therapy is not used.

    Reply

  3. Posted by Alan Wartenberg MD on July 31, 2018 at 6:38 pm

    There is no edit function. The “NOT” in the last sentence doesn’t belong there – it should be IS appropriate. Shades of Donald Trump!!

    Reply

  4. Posted by Alan Wartenberg MD on August 1, 2018 at 1:59 am

    What I actually meant to say, reading it over is that “use of antagonist therapy…. is not ONLY appropriate, but is becoming the standard of care if agonist therapy is not used.”

    Reply

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