Archive for the ‘methadone’ Category

Methadone maintenance is evidence-based medicine

“Prejudices, it is well known, are most difficult to eradicate from the heart whose soil has never been loosened or fertilized by education; they grow there, firm as weeds among stones.”
Charlotte Bronte

During the time I spent working at a methadone clinic, I admitted thousands of opioid addicts into treatment with methadone. For the first few years, I frequently questioned myself: was I doing more harm than good? It was easy to become discouraged. Our clinic was the target of frequent criticism from many sources: local newspapers, state government, families of addicts, and other healthcare professionals. Every time I got discouraged, I recalled the faces of addicts who did find recovery through methadone, and the dramatic changes that were possible not just for them, but for their entire families. It is an honor to be able to witness the miracle of change, and it does happen at methadone clinics.
I read summaries based on forty years of scientific studies regarding methadone’s effectiveness, and then knew that methadone treatment saves lives. “Evidence based” is a catch phrase now popular in all fields of medicine. It means that there is evidence – randomized controlled trials, preferably, as they are the best kinds of studies – that provides proof that a given treatment works. Mountains of evidence from multiple studies show that outcomes for opioid addicts are much better when they are maintained on methadone. So why did our clinics meet such opposition?
I don’t want to get to the end of my career and see that I have based my practice of medicine on inaccurate data, or worse, be blinded by my own prejudice. I often thought of the television clip of the tobacco executives, all in a row, hands raised as they swore tell the truth, and they all said they did not think tobacco was addictive. Why did they do that? Didn’t they feel ridiculous swearing to something that everyone knew was not true? Or worse….did they actually believe what they were saying? Maybe they became so blinded by ideology and economic interests that they believed their own rhetoric.
I don’t wish to make that mistake. I recognize how easy it is to be closed minded to treatment approaches that differ from one’s own. I listened closely to the opinions both for and against medication assisted treatments for opioid addiction. The people opposed to the use of methadone, and presumably buprenorphine, didn’t have facts to back their position, or at least not about methadone prescribed under accepted guidelines with appropriate controls against diversion. Most people who opposed methadone and buprenorphine said it wasn’t “real” recovery, and that they didn’t “believe” in it, as if it were some mythical beast like a unicorn. Addiction specialists who supported medication assisted recovery had evidence-based proof that it worked, and that many addicts could lead healthier and more productive lives.

Alcohol and Methadone Don’t Mix!!

Just like benzodiazepines, alcohol can be fatal when consumed by a patient who also takes methadone.

These two substances interact in several ways.

Worst of all, alcohol inhibits the area of the brain that keeps us breathing while we sleep. So do opioids of all sorts, including methadone. But when alcohol and methadone are both in the blood stream, the effects are greater than expected, due to synergy. In other words, 1+1=3, instead of 2, as we would expect. This interaction is unpredictable. This is how overdose deaths occur with the combination of alcohol and methadone.

Besides this potentially fatal interaction, alcohol also induces, or speeds up, the metabolism of methadone. Both alcohol and methadone are metabolized by the same enzymes in the liver, and alcohol can prime the pump of the metabolic rate. Alcohol gooses the liver, speeding the metabolism of methadone, which means a patient on a previously stable dose of methadone may suddenly notice that his dose isn’t holding for the full 24 hours. This patient may ask for a dose increase, when in truth, he really needs to stop drinking alcohol completely.

Over the long term, alcohol can cause a buildup of methadone to a toxic level, if the drinking goes on long enough to cause liver scarring and shrinkage, called cirrhosis. If this condition develops, liver metabolism slows for any drug or medicine processed by the liver.

Addiction is cunning, baffling, and powerful. It’s incredible to think of a person, finally able to stop using opioids after years of addiction, be defeated by alcohol. Cross addiction, which means switching from one addictive drug to another, happens all too frequently. Sometimes it’s hard to convince patients they need to stop the use of all addicting drugs, and that does include alcohol and marijuana.

Methadone does not rot teeth!

Yesterday I heard it again. I was examining a patient, transferring from out of state, who had been on methadone for several years. He was doing very well, and his life had improved greatly, but his teeth were in a bad state. He blamed this on methadone, and I couldn’t convince him otherwise.

First of all, teeth don’t get that bad in two years. Second, methadone does not weaken or rot teeth. Sometimes it seems that way, because after stabilizing on methadone, the recovering addict is no longer running around looking for drugs. He has more time for self-care. Taking stock, he sees bad teeth, and blames the methadone. In reality, the tooth decay is due to neglect during years of active addiction.

It’s important to get those teeth fixed, because dental pain is a common relapse trigger.

Dentists can be expensive. But you may live in a county that has low-cost dental services for people without insurance. Often you have to pay something, but the charges are based on ability to pay.

If you live near a dental school, you may be able to be seen there for free. When I was a medical student, an oral surgeon I met at a party needed to do three more extractions before he could graduate. I thought he was cute, so I told him about my ingrown wisdom teeth. Long story short…he never took ME out, but he did take my wisdom teeth out, and for free.

Why Does Dr. Drew Hate Methadone???

The short answer is: I don’t know. I have tried to find out; I have sent him two letters, one in care of the Pasadena Recovery Center, the site of his “Celebrity Rehab” show, and one to Hazelden, the well-known addiction recovery center in Minnesota that published his book “When Pain Pills Become Dangerous.” Pasadena sent my letter back to me, with a haughty “recipient not at this address” scrawled across it, and I got no answer at all from the letter I sent to Hazelden.
Judging from the remarks I’ve heard on his shows, I’m guessing he dislikes methadone because it is so difficult to taper off of, and the withdrawal lasts longer than other opioids. I agree with him about this. But he is treating different patient types than I am. He is treating celebrities, who seem to have the money to spend prolonged time in an inpatient treatment setting. This is a wonderful option for the people who can afford it. But many addicts don’t have this luxury, and to condemn a medication that can be life saving for so many suffering addicts is irresponsible.
For patients without financial resources, methadone can be life-saving, and Dr. Drew should be aware of the forty years’ studies that prove this.
I wish Dr. Drew could talk to some of my patients, to hear from them how much these medications can help. There are thousands of people in this country leading perfectly normal lives, who take a daily dose of methadone or buprenorphine (Suboxone). No one knows they are on these medications, because they don’t want to hear the negative comments stemming from the persistent stigma against these medications.

So Dr. Drew…if you’re out there, I’d like to hear from you.