Posts Tagged ‘methadone’

Book Review: “The Opioid Epidemic: What Everyone Needs to Know,” by Yngvild Olsen and Joshua Sharfstein

This is The Book. This is the one you need to read for evidence-based information on opioid use disorder, its treatment with medications, and what we can do to address the epidemic.

The prose is lean and easy to understand without talking down to readers. Published by Oxford University Press in 2019, it’s still relatively up to date. It’s a substantial read, at 344 information-packed pages.

I know of one of the authors, Dr. Olsen, from presentations she’s given at national ASAM meetings (American Society of Addiction Medicine). In fact, I just listened to a recorded presentation from spring of 2022 where she was one of the main presenters about how treatment regulations changed both before and after COVID 19. She’s been a leader in the field of Addiction Medicine, holding key positions in both federal and state organizations.

She knows what she’s talking about.

Her co-author, Dr. Sharfstein, is also a standout in the field. He teaches courses at Johns Hopkins’ Bloomberg School of Public Health, giving this book a depth of information not seen in others on the same topic.

The book, written in a question-and-answer format, starts at the first chapter by defining what opioids are and how they work. The authors make clear the difference between addiction and physical dependence, which is so often misunderstood. In that first chapter, the book also answers another common misperception: why using methadone or buprenorphine is not “just replacing one addiction with another.” The authors accomplished this so deftly that I knew the book was a winner.

In the second chapter, they describe how opioids are used for pain, and in the third chapter describe how misuse of opioids can start. Chapter 4 discusses what opioid addiction (opioid use disorder) is.

Chapter 5 covers what opioid overdose is and how it can be treated with naloxone. The authors dispel more myths in the chapter, like the one that says people using opioids will use more if they know naloxone is available to save them.

Chapter 6 does the heavily lifting of describing what is and is not effective treatment for opioid use disorder. The authors do a great job of describing treatment both in office-based practices and at opioid treatment programs. They cover methadone, buprenorphine, and naltrexone. They even touch on use of kratom and ibogaine as purported treatments with little information to recommend their use.

Chapter 7 covers treatment for pregnant patients. I was so happy to see their discouragement of the use of the phrase “addicted babies” as an outdated and improper term. Chapter 8 discusses use of opioids in teens and recommended treatments for this age group.

Chapter 9 focuses on questions that families of people with opioid use disorder often have. The book encourages the families while still warning them that opioid use disorder is a chronic illness. They discuss the term “enabling” and why allowing a family member to “hit rock bottom” may not be the best thing to do.

Chapter 10 talks about the supports people in recovery need, specifically housing and other essentials. They talk some about peer supports as well, and about 12-step meetings and how in some cases, 12-step meetings can be confusing for people new to recovery on MOUD.

Chapter 11 gives the historical perspective of the opioid epidemic in the U.S., going all the way back to just after the Civil War, and up to the age of fentanyl.

Chapters 12 through 16 are possibly the most helpful sections of this book, describing evidence-based policies that can help us in the areas of prevention, treatment, and harm reduction of opioid use disorder. There’s also a chapter about our failed war on drugs, explaining how we could better use law enforcement to help people enter treatment instead of jail.

I found myself in the “Amen!” corner while reading this book, excited to see evidence-based treatment options discussed so eloquently in a book.

I would recommend this book to any person who wants scientific information about opioid use disorder and its treatment. It’s an appropriate book for public health officials on all levels: federal, state, local, counties, etc.

It is as up to date as possible given its 2019 publication date, and I hope this is the first of many editions of this book. Things change quickly in the arena of opioid use disorder and its treatment, so we should be ready for a second edition soon.

Patient Impairment

Ukrainian art from ETSY: Alex Gru

Patients on MOUD (medications for opioid use disorder) need to dose daily for stability unless they are on depot-release forms of such medications such as Sublocade. We encourage patients to dose daily around the same time whether it’s from a take home dose or at our facility. Patients taking consistent and sufficient doses have reduced rates of overdose death, improved mental and physical health, and better employment.

However, sometimes it’s not safe to dose a patient. This can be due to a medical crisis that must be resolved, or due to impairment from sedative medication. It’s relatively rare for patients to arrive at their opioid treatment program with impairment, but it does happen, and physicians and providers need to be prepared for how to handle these events.

Sedatives like benzodiazepine (Xanax, Valium, Klonopin, and the like), alcohol, and other sedatives do not mix well with opioids. Both opioids and sedatives affect the part of the brain that tells us to breathe when we are asleep. People can die from single large doses of opioids, and they can also die if they mix sedatives and opioids. They go to sleep, stop breathing, and die from lack of oxygen to the brain, heart, and other important organs. This can happen quickly, as with a potent dose of fentanyl, or it can take much longer, perhaps hours, with longer-acting sedatives and opioids.

Before the patient gets to the unconscious stage, there’s often a period of impairment, when the patient doesn’t act or sound like their usual alert selves.

Impairment is defined, for these purposes, as a decline in mental function over baseline. Instead of being alert, the patient may be drowsy or inattentive. Instead of having clear speech with appropriate content, the patient may have slurred words, rambling or incoherent speech. There may be loss of control of motor function, leading to unsteady gait, stumbling, or even falling.

Impairment happens on a continuum; at one end a patient can be so impaired that he’s unconscious and needs to be revived with Narcan and CPR. At the other extreme, impairment might be so light that clinicians can’t detect it.

Part of our job at an OTP is to evaluate risks and benefits. If a patient is impaired, the risk of dosing her that day might outweigh the usual benefit of that dose.

Impairment must be evaluated by medical personnel. While receptionists, security guards or counselors can alert medical staff about a potential problem, the medical evaluation must be done by medical personnel.

This evaluation is done by the physicians or physician extenders unless there are none on site. In that case, an RN can gather data and evaluate for impairment. He or she can decide about the safety of dosing or may call the program physician for help with the decision. In our state of North Carolina, the Board of Nursing has said while RNs can work independently, LPNs cannot. LPNs can collect data but then must consult an RN, physician extender or physician to decide about the safety of dosing.

At our opioid treatment program, we take the patient to a private area. We don’t want to embarrass any patient in front of other people. I walk with my patient to my office, observing gait and balance. I try to be friendly and compassionate, realizing that the patient may be feeling fragile.

Once in my office I ask them how they are feeling, and about recent drug use or new medications. I listen to the content of what they tell me and to the delivery of their information. I listen for slurred speech or softening of consonants, speech content, and flow of conversation.

It’s helpful to get vital signs: temperature, blood pressure, heart rate, and respiratory rate. I add a pulse oximetry reading too. If these readings are abnormal, it can indicate a physical health problem as a cause of impairment. This can be serious and requires immediate medical investigation, usually at the local emergency department.

After talking to the patient, I turn to my computer and take my time typing data. While I do this, I watch the patient too. If she nods or falls asleep during conversational lulls, it’s probably not safe to dose her.

We have several tests we can ask the patient to do to test for motor impairment from sedatives. There’s the tandem gait test, which is what policemen do when they ask motorists to walk in a straight line. There’s the finger to nose test where the patient extends both arms, closes their eyes and brings the index finger to touch their nose.

My favorite is to ask my patient to stand on one foot for thirty seconds. It’s easy to do and I do it with them, so they won’t feel so put on the spot. Most people wobble a little but can keep their balance without touching down with the free foot or reaching for furniture.

We can also look for nystagmus of the eyes. This simple test, often misinterpreted by non-medical people, involves asking the patient to look to their extreme left or right. Then the examiner watches for slight bouncing of the eyes back and forth as the subject tries to keep their eyes in the extreme lateral position. Normal people can have one or two beats of nystagmus, but patients who have taken sedatives such as alcohol or benzodiazepines will have continued movement of their eyes.

Medical providers must remember that some medical crises can look like impairment from sedatives. A few months ago, a patient checked for impairment had a blood pressure of around 70/40 with an irregular heart rate into the 150’s, obviously in atrial fibrillation. We called the ambulance to take him to the hospital and he ultimately recovered.

Patients who are deemed to be impaired by medical providers often say they didn’t get any sleep the night before. This may be true, but lack of sleep shouldn’t cause slurred speech or problems with balance, unless they’ve been without sleep for days, in which case they probably need to go home and sleep before they get their next dose anyway.

It’s difficult for me to tell a patient they can’t be dosed that day. I know it will upset them and make them angry. I just keep trying to tell them that I’m refusing to dose them due to safety concerns, and that I’d rather they be angry with me but still alive.

Medical providers should expect a great deal of anger and should not take it personally.

We also try to get a urine sample for drug testing, thought that test won’t tell us if the patient is impaired. A urine drug screen only tells us if a given drug has been used in the recent past. Patients can be impaired with a negative drug and can be alert and fine to dose with a drug screen positive for multiple things.

Alcohol breath testing is the only drug where levels correlate with blood levels. Depending on the alcohol breath test, we can determine if the patient is under the influence of alcohol or not. The legal limit is .08, but patients on MOUD may be impaired at a much lower alcohol level, due to alcohol/drug interaction. We don’t dose patients if alcohol is detected.

After determining a patient to be too impaired to dose, I ask for help from the patient’s counselor. We must find a way to get them home without allowing the patient to drive. In big cities, public transportation takes care of this, but in our rural community, everyone drives everywhere because there is no public transportation. This can be difficult.

Also, we want to get permission to call a friend or family member to stay with our patient to watch them. We want to educate this person to call 911 if the patient becomes unresponsive and can’t be wakened, and make sure they know how to use Narcan, while waiting for EMS.

Anytime a patient can’t be dosed due to impairment, the physician must meet with the patient the next day, or as soon as possible. Impairment might be a warning that the patient has so little control over drug use that an inpatient treatment setting is indicated, at least temporarily.

Above all, it’s important to encourage the patient and let them know we care about what happens to them. We remind them part of our job is to make treatment as safe as possible. More than that needs to wait until the patient is clear and not impaired.

As I said in the beginning of this blog, impairment events are rare. Most of our patients never have such an episode. But when we do have a patient with impairment, we must be ready to intervene with compassion and good judgment about what is in the patient’s best interest.

The Facts About Methadone

methadone

The treatment of opioid addiction (heroin or prescription pain pills) with methadone still has an unwarranted stigma attached to it.  I wanted to devote at least one blog entry to a summary of the most well-known studies that support this evidence-based treatment. When people speak against methadone, they usually say they don’t “believe” in it, without being able to give any scientific basis for their stance. 

Well, this is why I do “believe” in it. It’s not opinion. It’s science.

 Amato L, Davoli, et. al., An overview of systematic reviews of the effectiveness of opiate maintenance therapies: available evidence to inform clinical practice and research. Journal of Substance Abuse Treatment 2005; 28 (4):321-329. In this overview of meta-analyses and other reviews, they conclude that methadone maintenance is more effective in the treatment of opioid addiction than methadone detoxification, buprenorphine, or no treatment. Higher doses of methadone are more effective than low or medium doses. 

Bale et. al., 1980; 37(2):179-193. “Therapeutic Communities vs Methadone Maintenance” Archives of General Psychiatry Opioid-addicted veterans who presented to the hospital for treatment were assigned to either inpatient detoxification alone, admission to a therapeutic community, or to methadone maintenance. One year later, patients assigned to therapeutic communities or methadone maintenance did significantly better than patients whose only treatment was detoxification. Patients in these two groups were significantly more likely to be employed, less likely to be in jail, and less likely to be using heroin, than the patients who got only detox admission. Patients in the therapeutic communities needed to stay at least seven weeks to obtain benefit equal to patients assigned to methadone maintenance. 

Ball JC, Ross A., The Effectiveness of Methadone Maintenance Treatment. New York, NY: Springer-Verlag Inc., 1991. This landmark study observed six hundred and thirty-three male patients enrolled in six methadone maintenance programs. Patients reduced their use of illicit opioids 71% from pre-admission levels, with the best results (no heroin use) seen in patients on doses higher than 70 milligrams. Longer duration of treatment with methadone showed the greatest reductions in heroin use. Of patients who left methadone maintenance treatment, 82% relapsed back to intravenous heroin use within one year. This study also found a dramatic drop in criminal activity for addicts in methadone treatment. Within one year, the number of days involved in criminal activity dropped an average of 91% for addicts maintained on methadone. This study showed that methadone clinics vary a great deal in their effectiveness. The most effective clinics had adequate dosing, well-trained and experienced staff with little turnover, combined medical, counseling and administrative services, and a close and consistent relationship between patients and staff.

 Caplehorn JRM, Bell J. Methadone dosage and retention of patients in maintenance treatment. The Medical Journal of Australia 1991;154:195-199. Authors of this study concluded that higher doses of methadone (80 milligrams per day and above) were significantly more likely to retain patients in treatment.

 Caplehorn JR, Dalton MS, et. al., Methadone maintenance and addicts’ risk of fatal heroin overdose. Substance Use and Misuse, 1996 Jan, 31(2):177-196. In this study of heroin addicts, the addicts in methadone treatment were one-quarter as likely to die by heroin overdose or suicide. This study followed two hundred and ninety-six methadone heroin addicts for more than fifteen years. 

Cheser G, Lemon J, Gomel M, Murphy G; Are the driving-related skills of clients in a methadone program affected by methadone? National Drug and Alcohol Research Centre, University of New South Wales, 30 Goodhope St., Paddington NSW 2010, Australia. This study compared results of skill performance tests and concluded that methadone clients aren’t impaired in their ability to perform complex tasks.

 Clausen T, Waal H, Thoresen M, Gossop M; Mortality among opiate users: opioid maintenance therapy, age and causes of death. Addiction 2009; 104(8) 1356-62. This study looked at the causes of death for opioid addicts admitted to opioid maintenance therapy in Norway from 1997-2003. The authors found high rates of overdose deaths both prior to admission and after leaving treatment. Older patients retained in treatment died from medical reasons, other than overdose.

 Condelli, Dunteman, 1993: examined data from TOPS, the Treatment Outcome Prospective Study, assessed patients entering treatment programs from 1979 – 1981 and found data on improvement similar to DARP; longer duration of treatment in methadone maintenance shows lower use of illicit opioids. 

Dole VP, Nyswander ME, Kreek, MJ, Narcotic Blockade. Archives of Internal Medicine, 1966; 118:304-309. Consisted of thirty-two patients, with half randomized to methadone and the other half to a no-treatment waiting list. The methadone group had much higher rates of abstention from heroin, much lower rates of incarceration, and higher rates of employment.

 Faggiano F, Vigna-Taglianti F, Versino E, Lemma P, Cochrane Database Review, 2003 (3) Art. No. 002208. This review article was based on a literature review of randomized controlled trials and controlled prospective studies that evaluated the efficacy of methadone at different doses. The authors concluded that methadone doses of 60 – 100mg per day were more effective than lower doses at prevention of illicit heroin and cocaine use during treatment.

 Goldstein A, Herrera J, Heroin addicts and methadone treatment in Albuquerque: a year follow-up. Drug and Alcohol Dependence 1995 Dec; 40 (2): p. 139-150. A group of heroin addicts were followed over twenty years. One-third died within that time, and of the survivors, 48% were on a methadone maintenance program. The author concluded that heroin addiction is a chronic disease with a high fatality rate, and methadone maintenance offered a significant benefit.

 Gordon NB, Appel PW., Functional potential of the methadone-maintained person. Alcohol, Drugs and Driving 1995; 11:1: p. 31-37. This is a literature review of studies examining performance and reaction time of patients maintained on methadone, and confirms that these patients don’t differ from age-matched controls in driving ability and functional capacity.

 Gowing L, Farrell M, Bornemann R, Sullivan LE, Ali R., Substitution treatment of injecting opioid users for prevention of HIV infection. The Cochrane Database of Systematic Reviews, 2008, Issue 2, Ar. No. CD004145. Authors reviewed twenty eight studies, concluded that they show patients on methadone maintenance have significant reductions in behaviors that place them at risk for HIV infection.

 Gronbladh L, Ohlund LS, Gunne LM, Mortality in heroin addiction: Impact of methadone treatment, Acta Psychiatrica Scandinavica Volume 82 (3) p. 223-227. Treatment of heroin addicts with methadone maintenance resulted in a significant drop in mortality, compared to untreated heroin addicts. Untreated addicts had a death rate 63 times expected for their age and gender; heroin addicts maintained on methadone had a death rate of 8 times expected, and most of that mortality was from diseases acquired prior to treatment with methadone. 

Gunne and Gronbladh, 1981: The Swedish Methadone Maintenance Program: A Controlled Study, Drug and Alcohol Dependence, 1981; 7: p. 249 – 256. This study conducted a randomized controlled trial on inpatient opioid addicts to methadone maintenance with intensive vocational rehabilitation counseling, or a control group that were referred to drug-free treatment.  Over 20 years, this study consistently showed significantly higher rates of subjects free from illicit opioids, higher rates of employment, and lower mortality in the group maintained on methadone than the control group.

 Hartel D, Selwyn PA, Schoenbaum EE, Methadone maintenance treatment and reduced risk of AIDS and AIDS-specific mortality in intravenous drug users. Abstract number 8546, Fourth Annual Conference on AIDS, Stockholm, Sweden, June 1988. This was a study of 2400 opioid addicts followed over fifteen years. Opioid addicts maintained on methadone at a dose of greater than 60mg showed longer retention in treatment, less use of heroin and other drugs, and lower rates of HIV infection. 

Hubbard RL, Marsden ME, et.al., Drug Abuse Treatment: A National Study of Effectiveness. Chapel Hill: University of North Carolina Press, 1989. Shows decreased use of illicit drugs (other than opioids) while in methadone treatment, and increased again after discharge.

 Kosten TR, Rounsaville BJ, and Kleber HD. Multidimensionality and prediction of treatment outcome in opioid addicts: a 2.5-year follow-up. Comprehensive Psychiatry 1987;28:3-13. Addicts followed over two and a half years showed that methadone maintenance resulted in significant improvements in medical, legal, social, and employment problems.

 Lenne MG, Dietze P, Rumbold GR, et.al. The effects of the opioid pharmacotherapies methadone, LAAM and buprenorphine, alone and in combination with alcohol on simulated driving. Drug Alcohol Dependence 2003; 72(3):271-278. This study found driving reaction times of patients on methadone and buprenorphine don’t differ significantly from non-medicated drivers; however, adding even a small amount of alcohol (.05%) did cause impairment.

 Marsch LA. The efficacy of methadone maintenance in reducing illicit opiate use, HIV risk behavior and criminality: a meta-analysis Addiction 1998; 93: pp. 515-532. This meta-analysis of studies of methadone concludes that methadone treatment reduces crime, reduces heroin use, and improves treatment retention.

 Mattick RP, Breen C, Kimber J, et. al.,Methadone maintenance therapy versus no opioid replacement therapy for opioid dependence. The Cochrane Database of Systematic Reviews,  2003; (2): CD002209. This is a meta-analysis of studies of methadone treatment. The authors concluded that treatment of opioid dependence with methadone maintenance is significantly more effective than non-pharmacologic therapies. Patients on methadone maintenance are more likely to be retained in treatment and less likely to be using heroin. This study did not find a reduction in crime between the two groups. 

Metzger DS, Woody GE, McLellan AT, et. al. Human immunodeficiency virus seroconversion amoung intravenous drug users in- and out- of- treatment: an 18-month prospective follow up. Journal of Acquired Immune Deficiency Syndrome 1993;6:1049-1056. Patients not enrolled in methadone maintenance treatment converted to HIV positivity at a rate of 22%, versus a rate of 3.5% of patients in methadone maintenance treatment.

 Powers KI, Anglin MD. Cumulative versus stabilizing effects of methadone maintenance. Evaluation Review 1993: Heroin addicts admitted to methadone maintenance programs showed a reduction in illicit drug use, arrests, and criminal behavior, including drug dealing. They showed increases in employment. Addicts who relapsed showed fewer improvements in these areas. 

Scherbaum N, Specka M, et.al., Does maintenance treatment reduce the mortality rate of opioid addicts? Fortschr Neurol Psychiatr, 2002, 70(9):455-461. Opioid addicts in continuous treatment with methadone had a much lower mortality rate (1.6% per year) than opioid addicts who left treatment (8.1% per year).

 Sees KL, Delucchi KL, et.al. “Methadone maintenance vs 180-day psychosocially enriched detoxification for treatment of opioid dependence” Journal of the American Medical Association, 2000, 283:1303-1310. Compared the outcomes of opioid addicted patients randomized to methadone maintenance or to180-day detoxification using methadone, with extra psychosocial counseling. Results showed better outcomes in patients on maintenance. Patients on methadone maintenance showed greater retention in treatment and less heroin use than the patients on the 180 day taper. There were no differences between the groups in family functioning or employment, but maintenance patients had lower severity legal problems than the patients on taper.

 Sells SB, Simpson DD (eds). The Effectiveness of Drug Abuse Treatment. Cambridge, MA: Ballinger, 1976: This was an analysis of information from DARP, the Drug Abuse Reporting Program, which followed patients entering three types of treatment from 1969 to 1972 and showed that methadone maintenance was effective at reducing illicit drug use and criminal activity. This study also demonstrated that addicts showed more improvement the longer they were in treatment. 

Strain EC, Bigelow GE, Liesbon IA, et. al. Moderate- vs high –dose methadone in the treatment of opioid dependence. A randomized trial. Journal of the American Medical Association 1999; 281: pp. 1000-1005. This study showed that methadone maintenance reduced illicit opioid use, and more of a reduction was seen with the addition of psychosocial counseling. Methadone doses of 80mg to 100mg were more effective than doses of 50mg at reducing illicit opioid use and improving treatment retention. 

Stine, Kosten; Medscape Psychiatric and Mental Health eJournal: article reminds us that though it’s clear that better outcomes for methadone patients are seen with higher doses (more than 80mg), many opioid treatment programs still underdose their patients.

 Zanis D, Woody G; One-year mortality rates following methadone treatment discharge. Drug and Alcohol Dependence, 1998: vol.52 (3) 257-260. Five hundred and seven patients in a methadone maintenance program were followed for one year. In that time, 110 patients were discharged and were not in treatment anywhere. Of these patients, 8.2% were dead, mostly from heroin overdose. Of the patients retained in treatment, only 1% died. The authors conclude that even if patients enrolled in methadone maintenance treatment have a less-than-desired response to treatment, given the high death rate for heroin addicts not in treatment, these addicts should not be kicked out of the methadone clinic.

 Do these studies mean that methadone works for every opioid addict? I don’t think so. Every medication has side effects and dangers. Methadone is no different. For a variety of reasons, methadone may not work for some addicts.  But this treatment has helped many addicts. At the very least, it can keep them alive until a better treatment comes along.

Description of Methadone Patients

The following is an excerpt from Chapter 2 of my book, titled, “Pain Pill Addiction: Prescription for Hope.” In this chapter I’m describing the patients I saw at methadone clinics where I worked in the years 2001 through 2009.

 I was surprised how casually people shared controlled substances with one another. As a physician, it seems like a big deal to me if somebody takes a schedule II or schedule III controlled substance that wasn’t prescribed for them, but the addicts I interviewed swapped these pills with little apprehension or trepidation. Taking pain pills to get through the day’s work seemed to have become part of the culture in some areas. Sharing these pills with friends and family members who had pain was acceptable to people in these communities.

In the past, most of the public service announcements and other efforts to prevent and reduce drug use focused on street drugs. Many people seemed to think this meant marijuana, cocaine, methamphetamine, and heroin. The patients I saw didn’t consider prescription pills bought on the street as street drugs. They saw this as a completely different thing, and occasionally spoke derisively about addicts using “hard drugs.” Most addicts didn’t understand the power of the drugs they were taking.

 Some opioid addicts came for help as couples. One of them, through the closeness of romance, transmitted the addiction like an infectious disease to their partner. Most were boyfriend/girlfriend, but some were married. The non-addicted partner’s motives to begin using drugs seemed to be mixed. Some started using out of curiosity, but others started using drugs to please their partner. I was disturbed to see that some of the women accepted the inevitability of addiction for themselves as the cost of being in a relationship with an addicted boyfriend. Often, addicted couples socialized with other addicted couples, as if opioid addiction bound them like a common fondness for bowling or dancing. Addiction became a bizarre thread, woven through the fabric of social networks.

 We saw extended family networks in treatment for pain pill addiction at the methadone clinics. One addicted member of a family came for help, and after their life improved, the rest of the addicted family came for treatment too. It was common to have a husband and wife both in treatment, and perhaps two generations of family members, including aunts, uncles, and cousins. Many addicts who entered treatment saw people they knew from the addicted culture of their area, and sometimes old disputes would be reignite, requiring action from clinic staff. Sometimes ex-spouses and ex-lovers would have to be assigned different hours to dose at the clinic, to prevent conflict.

 When the non-profit methadone clinic where I worked began accepting Medicaid as payment for treatment, we immediately saw much sicker people. Over all, Medicaid patients have more mental and physical health issues. Co-existing mental health issues make addiction more difficult to treat, and these patients were at higher risk for adverse effects of methadone. However, data does show that these sicker patients can benefit the most from treatment.

 When I started to work for a for-profit clinic, I saw a slightly different patient population. I saw more middle class patients, with pink and white-collar jobs. Occasionally, we treated business professionals. The daily cost of methadone was actually a little cheaper at the for-profit clinic, at three hundred dollars per month, as compared to the non-profit clinic, at three hundred and thirty dollars per month. However, the for-profit clinic charged a seventy dollar one-time admission fee, to cover the costs of blood tests for hepatitis, liver and kidney function, blood electrolytes, and a screening test for syphilis. The non-profit clinic had no admission fee, but only did blood testing for syphilis. I believe the seventy dollars entry fee was enough to prevent admission of poorer patients, who had a difficult enough time paying eleven dollars for their first and all subsequent days.

The patients at the for-profit clinic seemed a little more stable. Maybe they hadn’t progressed as far into their disease of addiction, or maybe they had better social support for their recovery. This clinic didn’t accept Medicaid, which discouraged sicker patients with this type of health coverage. Both clinics were reaching opioid addicts; they just served slightly different populations of addicts. The non-profit clinic accepted sicker patients, which is noble, but it made for a more chaotic clinic setting. This was compounded by a management style that was, in a few of their eight clinics, more relaxed.

 For the seven years I worked for a non-profit opioid treatment center, I watched it expand from one main city clinic, and one satellite in a nearby small town, to eight separate clinic sites. The treatment center did this because they began to have large numbers of patients who drove long distances for treatment. This indicated a need for a clinic to be located in the areas where these patients lived. Most of this expansion occurred over the years 2002 through 2006.

 Three of these clinics were located in somewhat suburban areas, within a forty-five minute drive from the main clinic, located in a large Southern city. The other four clinics were in small towns drawing patients from mostly rural areas. One clinic was located in a small mountain town that was home to a modest-sized college. Nearly all of the heroin addicts I saw in the rural clinics were students at that college. But by 2008, we began to see more rural heroin addicts, who had switched from prescription pain pills to heroin, due to the rising costs of pills.

Within a few years, clinics near the foothills of the Blue Ridge Mountains of Western North Carolina were swamped with opioid addicts requesting admission to the methadone clinics. These clinics soon had many more patients than the urban clinic.

I saw racial dissimilarities at the clinic sites. In the city, we admitted a fair number of African Americans and other minorities to our program. Most of them weren’t using pain pills, but heroin. I don’t know why this was the case. Perhaps minorities didn’t have doctors as eager to prescribe opioids for their chronic pain conditions, or perhaps they didn’t go to doctors for their pain as frequently as whites. If they were addicted to pain pills, maybe distrust kept them from entering the methadone clinic. In the rural clinics, I could count the number of African-American patients on one hand. They were definitely underrepresented. The minorities we did treat responded to treatment just as well.

A recent study of physicians’ prescribing habits suggested a disturbing possibility for the racial differences I saw in opioid addiction. (1) This article showed statistically significant differences in the rate of opioid prescriptions for whites, compared to non-whites, in the emergency department setting. Despite an overall rise in rates of the prescription of opioid pain medication in the emergency department setting between 1993 and 2005, whites still received opioid prescriptions more frequently than did Black, Asian, or Hispanic races, for pain from the same medical conditions. In thirty-one percent of emergency room visits for painful conditions, whites received opioids, compared to only twenty-three percent of visits by Blacks, twenty-eight percent for Asians, and twenty-four percent for Hispanic patients. These patients were seen for the same painful medical condition. The prescribing differences were even more pronounced as the intensity of the pain increased, and were most pronounced for the conditions of back pain, headache, and abdominal pain. Blacks had the lowest rates of receiving opioid prescriptions of all races.

This study could have been influenced by other factors. For example, perhaps non-whites request opioid medications at a lower rate than whites. Even so, given the known disparities in health care for whites, versus non-whites in other areas of medicine, it would appear patient ethnicity influences physicians’ prescribing habits for opioids. The disparities and relative physician reluctance to prescribe opioids for minorities may reduce their risk of developing opioid addiction, though at the unacceptably high cost of under treatment of pain.

Interestingly, we had pockets of Asian patients in several clinics. We admitted one member of the Asian community into treatment, and after they improved, began to see other addicted members of their extended family arrive at the clinic for treatment. Usually the Asian patients either smoked opium or dissolved it in hot water to make a tea and drank it. When I tried to inquire how much they were using each day, in order to try to quantify their tolerance, the patient would put his or her thumb about a centimeter from the end of the little finger and essentially say, “this much.” Having no idea of the purity of their opium, this gave me no meaningful idea of their tolerance, so we started with cautiously low doses.

One middle aged patient from the Hmong tribe presented to the clinic and when I asked when and why he started opioid use, in broken English and with difficulty, he told me he had lost eight children during the Vietnam War, and was injured himself. After the pain from his injury had resolved, he still felt pain from the loss of his family and he decided to continue the use of opium to treat the pain of his heart, as he worded it. I thought about how similar his history was to the patients of the U.S. and how they often started using opioids and other drugs to dull the pain of significant loss and sorrow. I thought about how people of differing ethnicities are similar, when dealing with addiction, pain, and grief.

1. Pletcher M MD, MPH, Kertesz, MD, MS, et. al., “Trends in Opioid Prescribing by Race/Ethnicity for Patients Seeking Care in US Emergency Departments,” Journal of the American Medical Association, 2008 vol. 299 (1) pp 70-78.

Urine Drug Screens for methadone and Suboxone (buprenorphine)

Many patients who are prescribed methadone or buprenorphine (better known to some as Suboxone) are concerned about their employment drug screens. Because of the stigma attached to opioid addiction and its treatment with methadone or buprenorphine, patients don’t want their employers to know about these medications, and thus about their history of addiction.

Most companies who do urine drug screening hire a Medical Review Officer (MRO), who is a doctor specifically trained to interpret drug screen results. This doctor is a middle man between the employer and the employee, and though this doctor may ask for medical information, and information about valid prescriptions, this doctor usually can’t tell the employer this personal information. The MRO reports the screen as positive or negative, depending on information given to her.

Most employment urine drug screens check for opiates, meaning naturally-occurring substances from the opium poppy, like codeine and morphine. Man-made opioids like methadone, buprenorphine, and fentanyl, to name a few, won’t show as opiates on these drug screens.

A few employers do drug screening that specifically checks for hydrocodone or oxycodone. This is infrequent. It’s rare for employers to screen for methadone, and they almost never screen for buprenorphine, unless the patient is a healthcare professional being monitored by a licensing agency. The screen for buprenorphine is pricey, so the only doctors who tend to screen for it regularly are the ones prescribing buprenorphine. These doctors want to make sure their patients are taking, not selling, their medication.

Patients ask if they should tell their employer they are on methadone or buprenorphine. In general, that’s probably a bad idea, unless it’s a special situation. So long as you can do your job safely, your medical problems aren’t any of your boss’s business.

The only exceptions to this are if you work in a “safety sensitive” job. This includes medical professionals, transit workers, pilots, and the like. These jobs may require disclosure of medical issues to protect public safety. For example, to get a commercial driver’s license (CDL), you have to be free from illnesses which may cause a sudden loss of consciousness behind the wheel.

The Dept. of Transportation still says that if you are taking methadone for the treatment of addiction, you can’t be granted a CDL. However, most of the studies done on methadone-maintained patients shows their reflexes are the same as a person not on methadone, so there’s no real scientific reason for the DOT’s decision. (1, 3, 4) Besides, since the urine drug screen for a driver’s physical doesn’t include methadone, they won’t know unless you tell them.

Patients can be impaired, and unable to drive safely, if they have just started on methadone, haven’t become accustomed to it, or are on too high a dose. These patients shouldn’t be behind the wheel until they are stable, even in a car, let alone an 18-wheeler. Methadone patients are likely be impaired and unable to drive if they abuse benzodiazepines. They shouldn’t drive any kind of vehicle. Ditto for alcohol. (2, 5)

1. Baewert A, Gombas W, Schindler S, et.al., Influence of peak and trough levels of opioid maintenance therapy on driving aptitude, European Addiction Research 2007, 13(3),127-135. This study shows that methadone patients aren’t impaired at either peak or trough levels of methadone.

2. Bernard JP, Morland J et. al. Methadone and impairment in apprehended drivers. Addiction 2009; 104(3) 457-464. This is a study of 635 people who were apprehended for impaired driving who were found to have methadone in their system. Of the 635, only 10 had only methadone in their system. The degree of impairment didn’t correlate with methadone blood levels. Most people on methadone who had impaired driving were using more than just methadone.

3.Cheser G, Lemon J, Gomel M, Murphy G; Are the driving-related skills of clients in a methadone program affected by methadone? National Drug and Alcohol Research Centre, University of New South Wales, 30 Goodhope St., Paddington NSW 2010, Australia. This study compared results of skill performance tests and concluded that methadone clients aren’t impaired in their ability to perform complex tasks.

4.Dittert S, Naber D, Soyka M., Methadone substitution and ability to drive. Results of an experimental study. Nervenartz 1999; 70: 457-462. Patients on methadone substitution therapy did not show impaired driving ability.

5.Lenne MG, Dietze P, Rumbold GR, et.al. The effects of the opioid pharmacotherapies methadone, LAAM and buprenorphine, alone and in combination with alcohol on simulated driving. Drug Alcohol Dependence 2003; 72(3):271-278. This study found driving reaction times of patients on methadone and buprenorphine don’t differ significantly from non-medicated drivers; however, adding even a small amount of alcohol (.05%) did cause impairment.

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.