Driving on Methadone

 

 

 

 

“How can you let those people get behind the wheel and drive after you shoot ‘em up with methadone?”

This question, frequently asked by law enforcement and other people, reveals key misunderstandings about the pharmacology of methadone. That’s OK; I don’t expect laypeople to know methadone pharmacologic principles. Oh, and we don’t “shoot them up.” We give them controlled oral doses of methadone measured to the nearest milligram of liquid, and observe our patients consume this medication on site.

While laypeople may not have a reason to understand medication-assisted treatment, I think it’s essential for law enforcement officers to understand. They need to know why our patients are not impaired when they leave our parking lots after dosing.

When patients on methadone (or buprenorphine) are dosing every day, they have a tolerance to the drowsiness that opioids cause opioid-naïve people. Our patients, assuming they have reached a stable dose and aren’t using any other drugs, have blood levels of medication that don’t fluctuate much through the day. Because methadone is such a long-acting medication, the blood level doesn’t even reach its peak until around three hours after dosing.

Because of the frequent misunderstandings and assumptions of law enforcement personnel, I’ve composed a sample letter that opioid treatment programs may forward to the law enforcement officer of their choice.

Dear Officer Zealous:

First of all, thank you for patrolling our streets and highways and for your efforts to keep them safe. I know you have a difficult job and I deeply appreciate your willingness to take on this responsibility.

However, please stop arresting my patients for whom I’ve prescribed methadone and buprenorphine (better known under the brand names Suboxone, Subutex, or Zubsolv). You mistakenly think all people taking these medications have no right to be driving, and you are wrong. I’m writing this letter to give you better information, so you can do your job more efficiently.

Our nation is in the middle of a crisis. Opioid use disorder is an epidemic, and too often its sufferers die of overdoses. Treatment of this disease with methadone and buprenorphine works very well to prevent overdose deaths, and it’s been proven to help patients have a better quality of life in recovery.

I doubt you’ve been provided any information about this type of treatment, so I want to offer data to you.

Methadone has been around for fifty years and has a proven track record. It’s been studied more than perhaps any other medication, and we know it does a great job of treating opioid use disorder. Buprenorphine has only been available in the U.S. for about 17 years, but has been used in Europe for decades with success.

With both methadone and buprenorphine, the proper dose of medication should make the patients feel normal. Patients should not feel intoxicated or high, and should not feel withdrawal symptoms as the day wears on. Methadone and buprenorphine are both very long-acting opioids, and can be dosed once per day. They both can provide our patients with a relatively steady level of medication, compared to short-acting opioids usually used for intoxication. Therefore, using methadone to treat opioid addiction is not “like giving whiskey to an alcoholic,” as has incorrectly been asserted. The valid difference lies in the unique pharmacology of methadone. Opioid addicts can lead normal lives on this medication, when it is properly dosed.

In addition, both of these medications block other opioids at the opioid receptor. When a patient is on an adequate dose of methadone or buprenorphine, if she relapses and uses an illicit opioid, the medication blocks the effects of the illicit opioid. The patient feels no euphoria, which reduces the urge to use illicit opioids in the future. Both methadone and buprenorphine work in this way to deter use of other opioids for the purpose of getting high.

Treatment of opioid addiction with methadone and buprenorphine is endorsed by the CSAT (Center for Substance Abuse Treatment) branch of SAMHSA, by the U.S.’s Institute of Medicine, by ASAM (American Society of Addiction Medicine), by AAAP (American Association of Addiction Psychiatry), and by NIDA (National Institute of Drug Addiction. In study after study, methadone has been shown to reduce the risk of overdose death, reduce days spent in criminal activities, reduce transmission rates of HIV, reduce the use of illicit opioids, reduce the use of other illicit drugs, produce higher rates of employment, reduce commercial sex work, and reduce needle sharing. Medication-assisted therapy is also high cost effective.

Indeed, the current debate of government officials at the highest levels has been how best to expand medication-assisted treatment with methadone and buprenorphine, not to make it less available. So please don’t do anything which may discourage opioid addicts from receiving life-saving treatment.

Over the years, many studies have been done on methadone and buprenorphine to see if patients are able to drive safely on either of them. In study after study, data show patients on stable doses of both medications can safely drive cars, operate heavy equipment, and perform complex tasks. Please see the list of references at the bottom of this letter if you wish to investigate for yourself.

I’m not saying, however, that patients on methadone or buprenorphine can’t become impaired. Impairment can occur if patients are given too high a dose of methadone or buprenorphine, which most often occurs during the first two weeks of treatment. For that reason, patients are warned not to drive if they ever feel sedated or drowsy.

Patients on medication-assisted treatment can also become impaired if they mix other drugs or medications with their methadone or buprenorphine. In fact, benzodiazepines (like Xanax, Valium, Klonopin) and alcohol act synergistically with maintenance opioids. They can cause impairment with smaller amounts of alcohol or benzos than expected. And of course, patients can still become impaired with other drugs, such as marijuana.

As you probably know, a urine drug screen won’t detect impairment. The urine screen only tells you if a person has taken a given drug or medication over the last few days to weeks. Drugs are detectable in the urine long after the impairing effect wears off.

You can do blood tests, but these aren’t useful for patients on methadone. The dose required to stabilize one of my patients would impair or even kill a person who’s never taken opioids, so the meaning of the blood level depends on the patient’s experience and history.

My family and I drive these roads too, and I don’t want impaired drivers on our highways any more than anyone else. However, due to your desire to do a good job, you have mistakenly targeted patients on medication-assisted treatment for the disease of opioid addiction.

I know you have formed bad opinions about methadone and buprenorphine patients from seeing both drugs misused on the street. I hate that, because you probably rarely get to see our more typical patients on medication-assisted treatments.

The vast majority of my patients have jobs, families, and responsibilities that they meet, despite having this potentially fatal illness of opioid addiction. If you are fortunate enough to encounter one of my patients on a random traffic stop, please don’t give them a hard time. Please congratulate them on having the courage to find recovery from addiction, and tell them to do what works for them. In some patients, that means medication-assisted treatment.

Thanks for reading this long letter and thanks for all you do in the name of keeping our roads safe. If you want to know more about how we treat opioid use disorder at our facility, please call our program manager at xxx-xxx-xxxx and we would be happy to provide you with an after- hours tour and lots of information.

Sincerely,

 

Jana Burson M.D.

Member of the American Society of Addition Medicine

Board certified in Internal Medicine

Certified by the American Board of Addiction Medicine

P.S. And please don’t attempt to intimidate patients from coming to get help for this fatal illness of opioid use disorder by parking your squad car just outside our facility’s entrance. Some of these patients may have old warrants, but by stalking them where they come for help, you discourage people who want to escape addiction and want to better their lives. If you do park near us, you should expect a staff member to approach you with a smile, a cup of coffee, and a pile of information about opioid addiction and its treatment.

 

Methadone and Driving Article Abstracts

Brief Literature Review

Institute for Metropolitan Affairs

Roosevelt University 2/14/08

  1. DRIVING RECORD OF METHADONE MAINTENANCE PATIENTS IN NEW YORK STATE

BABST, D., NEWMAN, S., & State, N. (1973). DRIVING RECORD OF METHADONE MAINTENANCE PATIENTS IN NEW YORK STATE. DRIVING RECORD OF METHADONE MAINTENANCE PATIENTS IN NEW YORK STATE,

When a comparison was made within specific age groups, it was learned that the accident and conviction rates were about the same for methadone maintenance clients as for a sample of New York City male drivers within the same period. The findings from other related studies discussed in this booklet are consistent with the results in this study.

2. The effects of the opioid pharmacotherapies methadone, LAAM and buprenorphine, alone and in combination with alcohol, on simulated driving.

Lenné, M., Dietze, P., Rumbold, G., Redman, J., & Triggs, T. (2003, December). Drug & Alcohol Dependence, 72(3), 271.

These findings suggest that typical community standards around driving safety should be applied to clients stabilized in methadone, LAAM and buprenorphine treatment.

3. Maintenance Therapy with Synthetic Opioids and Driving Aptitude.

Schindler, S., Ortner, R., Peternell, A., Eder, H., Opgenoorth, E., & Fischer, G. (2004). Maintenance Therapy with Synthetic Opioids and Driving Aptitude. European Addiction Research, 10(2), 80-87

Conclusion: The synthetic opioid-maintained subjects investigated in the current study did not differ significantly in comparison to healthy controls in the majority.

4. Methadone-substitution and driving ability
Forensic Science International, Volume 62, Issues 1-2, November 1993, Pages 63-66
H. Rössler, H. J. Battista, F. Deisenhammer, V. Günther, P. Pohl, L. Prokop and Y. Riemer

The formal assertion that addiction equals driving-inability, which is largely practiced at present, is inadmissible and therefore harmful to the therapeutic efforts for rehabilitation.

5. Methadone substitution and ability to drive. Results of an experimental study.

Dittert, S., Naber, D., & Soyka, M. (1999, May).

It is concluded that methadone substitution did not implicate driving inability.

6. Functional potential of the methadone-maintenance person.

Gordon, N., & Appel, P. (1995, January). Functional potential of the methadone-maintenance person. Alcohol, Drugs & Driving, 11(1), 31-37.

Surveys on employability and driving behavior of MTSs revealed no significant differences when compared to normal population. It is concluded that MM at appropriate dosage levels, as part of treatment for heroin addiction, has no adverse effects on an individual’s ability to function.

7. Influence of Peak and Trough Levels of Opioid Maintenance Therapy on Driving Aptitude. Baewert, A., Gombas, W., Schindler, S., Peternell-Moelzer, A., Eder, H., Jagsch, R., et al. (2007). European Addiction Research, 13(3), 127-135.

This investigation indicates that opioid-maintained patients did not differ significantly at peak vs. trough level in the majority of the investigated items and that both substances do not appear to affect traffic-relevant performance dimensions when given as a maintenance therapy in a population where concomitant consumption would be excluded.

8. The influence of analgesic drugs in road crashes.

Chesher, G. (1985, August). The influence of analgesic drugs in road crashes. Accident Analysis & Prevention, 17(4), 303-309.

Methadone, as used in treatment schedules for narcotic dependence, produces no significant effect on measures of human-skills performance.

9. Influence of narcotic drugs on highway safety.

Gordon, N. (1976, February). Influence of narcotic drugs on highway safety. Accident Analysis & Prevention, 8(1), 3-7.

A review of the literature on narcotic drug use and driver safety indicates that narcotic users do not have driving safety records that differ from age-matched individuals in the general population. Maintenance on methadone also does not appear to increase driving risk.

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6 responses to this post.

  1. Posted by deb breitrick on June 30, 2019 at 3:18 pm

    I love this!

    All the Best,

    Deb

     

    Deb Breitrick 

    Cell 920.287.2590

    Maximizer – Positivity – Relator – Includer – Connectedness

     

     

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    Reply

  2. Posted by Maria Scott on June 30, 2019 at 11:28 pm

    Oh I love this article so much, and how this doctor stood up for her patients, I live in Clearwater and the same thing happens there, I only go once a week and I will see a cop sitting there and you know it’s to intimidate us but it doesn’t me I just wave to them 👋. We are normal people just like everyone else. We just have to fight harder on the daily.

    On Sun, Jun 30, 2019, 10:47 AM Janaburson’s Blog wrote:

    > janaburson posted: ” “How can you let those people get behind the > wheel and drive after you shoot ‘em up with methadone?” This question, > frequently asked by law enforcement and other people, reveals key > misunderstandings about th” >

    Reply

  3. Posted by Bryan PN on July 1, 2019 at 4:52 am

    Methadone does not block other stronger for mu receptor agonist activity!!

    Sincerely;

    Bryan Paul Negrini, MD, MPH Cell 412-651-9095 President, Prometheus Group of Companies: Opioid Addiction Recovery Services. Balanced Health Care Solutions. Impressions Art Holdings. Alerica.

    The above was sent from my personal iPhone. Dictated texts and emails are often not reviewed prior to sending and I apologize for any voice recognition errors. This signature stamp serves for all of my outgoing Communications.

    >

    Reply

    • Yes you are right; I was oversimplifying in my statement, but didn’t feel getting into the weeds about affinity for receptors, etc, would be appreciated.

      Reply

  4. Posted by Katie B. on July 5, 2019 at 9:29 am

    I love reading your blog. I think that you highlight the positives about addiction medicines and have been reading quietly for a couple of years. I have some questions about this one though. Please understand I take no stance here and have no dog in the fight, but a couple of points:
    1. The police officers do not automatically know that a driver is on methadone just because they run the tag, check the license, or any other standard actions that occur during a traffic stop.
    2. They can’t pull over someone without reasonable suspicion that a crime was being committed, is being committed, or is about to be committed. In other words, unless it’s a check point there is no just pulling over someone for no reason.
    3. A person isn’t just arrested for DUI for no reason. There has to be enough evidence to move that reasonable suspicion to probable cause that the driver is actually impaired. This means actual evidence that will hold up in court against a criminal defense/ public defender trying to disprove the evidence. This is why sobriety test are performed, and in fact if a breathalyzer is performed and shows 0.00 the evidence that the driver was impaired becomes even more important to the case (No breath test numbers to fall back on.)
    The idea that police are just watching the parking lot waiting to pull over someone with no other evidence other than they just dosed would be ripped apart in court and would leave the agency open for liability for civil rights violation. I think you would be hard pressed to find a magistrate who would actually accept a dui in the first place based solely on the fact that the driver takes methadone.
    There is so much more information to put here, but it’s not my blog so I will wrap this up. In conclusion, it sounds like maybe there is a misunderstanding on both sides here. If we are going to prepare a letter for them, and expect that they have some empathy towards our culture in addiction treatment; we should realize that empathy works both ways. While they might not understand what we do; we might not understand very much about what they do.

    Reply

  5. Posted by Jane D on July 9, 2019 at 6:36 pm

    Hi Jana,
    I am a research coordinator. I have been following your blog to get information on opioids as we are doing a project on substance exposed newborns. Thank you for being such a voice of information, practical and reasonable and understandable, amidst all the hype and fear. Commenting today to send you a link in return. I only read the article, have not yet listened, but it is interesting. https://www.npr.org/sections/health-shots/2019/07/08/738952129/motorcycle-crash-shows-bioethicist-the-dark-side-of-quitting-opioids-alone. Especially his comments about the difficulty and expense of other treatments for pain, versus the ease of prescribing and inexpense of opioids. Again we have our priorities backwards it seems. But I am thankful for people like you and Mr Rieder for sharing info and speaking up. Finally, thank you for all the thought and reading and conferences attended to keep yourself, and your blog audience, so informed.
    Jane D – Baltimore, MD

    Reply

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