Category Archives: Methadone Safety

Methadone and Other Medications

doc66Methadone is FDA-approved for pain management and the treatment of opioid addiction. Methadone is a relatively safe and highly effective medication when used exactly as prescribed. It is currently in use in the United States and around the world following years of conclusive research on methadone’s efficacy and safety.

It is important for patients receiving methadone to know that it can interact with other central nervous system depressants like alcohol and benzodiazepines such as xanax, klonopin, valium, and librium as well as similarly acting non-benzodiazepine agents like ambien (a popular sleep aid). When methadone is mixed with these other medications, there is an increased risk of sedation and loss of consciousness. In extreme cases, individuals mixing methadone and other CNS depressants have gone into respiratory failure.

For those who have chosen to receive methadone in an opioid treatment program, they will discover that a proper dose of methadone not only eliminates opiate withdrawal & cravings, but will also block the euphoric effects of any other opiates. This is typically a positive side effect in that it discourages illicit opiate use or supplementing with street drugs like heroin. Since methadone binds so well to the brain’s opiate receptor sites, any other opiates that are ingested have no means of creating a euphoria or a high since the body’s opiate receptors are occupied by methadone. This removes the incentive to misuse other opiates and can facilitate the process of recovery.

There are instances in which a patient’s physician has prescribed a benzodiazepine for anxiety management while also prescribing methadone. Such decisions should always be accompanied by a thorough discussion with one’s doctor of the potential risks & complications. There are other, safer alternatives for treating anxiety such as Buspar and cognitive therapy. These other options should be considered when a patient is already receiving methadone. In addiction treatment, the use of benzodiazepines for anxiety is typically monitored carefully through increased random urinalysis testing and medication counts.

Methadone Dosage Increases

methadone-increaseWhen a new client joins a methadone program, they go through a process called induction. Induction is the initial delivery of a methadone dose and the subsequent increases in dosage over the next 1 to 2 months as the medical team help get the client stabilized & comfortable on a dose of methadone that effectively eliminates their painful opioid withdrawal symptoms.

Induction is historically a high risk span of time since there is an increased risk of accidental overdose with methadone. It is extremely rare that overdose occurs during induction especially if clients are abstaining from other illicit substances during the induction process.

Therein lies the dilemma. Some clients become impatient with the process of methadone induction and will supplement their methadone dose with other unapproved opiates or benzodiazepines. This is dangerous and actually undermines the benefit of what methadone can achieve for the patient.

To help the treatment team determine the level of methadone increase to provide a patient, they use the Clinical Opiate Withdrawal Scale, or COW Scale. This is a withdrawal assessment tool that helps the clinical or medical team determine the prevalence and severity of opioid withdrawal symptoms. The scale produces a score based on the client’s reported symptoms and the team’s observation of withdrawal symptoms. The higher the COW scale score, the more severe the symptomology and thus a greater justification for allowing a higher dosage increase.

Some clinics are known to take clients up 10 mg at a time. Many physicians consider this high risk and too rapid of an increase. Note that methadone is a slow acting, long lasting opioid agonist with a much longer half life than heroin and most other prescription opioids. What this means is that methadone stays in the system much longer and builds cumulatively over time. So the actual effect of a dosage increase is not immediately felt and may take 1-3 days before the full effect of that dosage increase is realized.

With an impatient client, they may receive a dosage increase but not feel the immediate relief they were hoping for. Consequently, they may use additional unapproved opiates that then mix with the methadone increase that is still being absorbed into their system. This puts the client at risk of overdose.

Many clinics use 5 mg increases every few days while some clinics adjust each requested increase in accordance with the COW Scale score. For example, a client may receive several 5 mg increases because they have moderately severe withdrawal symptoms, but then receive a 3 mg increase days later and possibly a 2 mg increase days after that as the symptom severity begins to diminish. This more cautious approach reduces the risk of overdose while still addressing the client’s unresolved physical discomfort.

A well-managed methadone induction is tailored to the individual client’s needs, and the client’s safety is always the chief concern. Methadone dosage increases are provided only to alleviate measurable physical withdrawal symptoms or closely associated anxiety, restlessness, or psychological distress from withdrawal.

Methadone Programs and Prohibited Medications

rx-medication-abuseMany clients in methadone programs have co-occurring disorders like depression, anxiety, or adult attention deficit disorder (ADD). Historically, clinics have attempted to treat psychiatric symptoms with established, FDA-approved psychotropic medications which have proven useful across many settings in managing symptoms.

In the past decade, it became very apparent that benzodiazepines (commonly prescribed to treat anxiety) had become a popular alternative drug of abuse for individuals with an opioid addiction. “Benzos” are a particularly dangerous medication when used in conjunction with methadone, and the combination of these two contributed to a number of overdose deaths in recent years.

For this reason, many safety-oriented, reputable methadone clinics (and independent physicians) either discontinued or noticeably restricted their use of benzodiazepine medications with patients on methadone. Common benzodiazepines include prescription meds like klonopin, valium, xanax, and ativan. As an alternative to these high risk medications, non-addictive options like Buspar are utilized to help clients better manage their anxiety symptoms as well as cognitive therapies for teaching stress reduction and anxiety management skills.

Stimulant therapy is the use of stimulant-based medications to aid adults struggling with attention deficit disorder. Popular medications in this class include adderall, ritalin, and concerta. Unfortunately, these medicines are also widely abused and often illegally sold by patients thus forcing treatment providers to reconsider the use of these medications in their programs.

Positively, there are several medications which can help ADD and which have a low abuse potential. Some psychotropic medications can also be used off label to help reduce attention deficit problems. Off label means the drug was not designed specifically to treat a symptom, but has been found to have a beneficial effect on reducing that symptom.

In the end, methadone programs must employ the safest protocols to insure that clients receive treatment that genuinely helps them and will not place them at risk. There are instances in which benzodiazepines and stimulant therapies are appropriate and in the best interest of the client. However, medical and clinical staff must utilize a careful sense of discretion and evaluate the merits of a particular high risk medication against its potential for harm.

Clients can help this process by being open, honest, and direct with their treatment staff. Clients should report to management any person who is known to sell prescription medications to other clients. While this type of behavior typically occurs among a minority, it can have an extremely negative impact on other clients and the clinic itself.

Safety and Security With Methadone

methadone-safetyIf you are currently a client in a methadone clinic, then you have most likely heard treatment staff emphasize the importance of safety with methadone and the necessity of carefully securing take home methadone doses. Methadone is a powerful medication that is tremendously helpful to recovering individuals. It is also potentially lethal in the wrong hands and consequently must be deliberately safeguarded.

There is a recently published article on Bloomberg regarding methadone being diverted and then taken by someone who later died from an overdose. This turn of events has led to newly proposed legislation in five states (Maine, Indiana, Minnesota, West Virginia, and Pennsylvania) that would further tighten regulations regarding the operation of methadone clinics and their award of methadone take home medication to their clients.

The reported misuse of methadone, and associated deaths, was allegedly tied to several private, for-profit clinics that operate in these states. One of the criticisms of the private, for-profit clinics was that they are not providing "enough services". This is intended to mean that the clinics in question were not providing sufficient education & counseling support or adequate monitoring of those who receive take home methadone.

It is critically important that all methadone clinics (both private and publicly supported) implement thorough measures to educate clients on methadone safety concerns as well as institute monitoring protocols like 24 hour callbacks and random drug testing. 24 hour callbacks require take home recipients to return to their home clinic within 24 hours and to produce their methadone take home doses for count and inspection by the clinic's medical staff.

It is also important that methadone clinics only award take home medication privileges to those clients who have achieved certain progress milestones such as successive months of clean urinalysis, attendance to required counseling sessions, the absence of criminal charges, and demonstrated appropriate behaviors & attitude toward staff and peers at the clinic.

When individuals intentionally divert methadone doses or mishandle methadone through lax practices (such as leaving it sitting out in plain view), they put others at risk and ultimately undermine the delivery of methadone services in the community. In other words, the mistakes of a few can negatively affect everyone. This also erodes the community's confidence in methadone as a life-saving medical treatment.

In the end, it is the shared responsibility of all methadone clinics and their clients to insure that methadone is taken as prescribed, and safeguarded from diversion. When proper precautions are not honored, tragedies will occur. This will lead to state legislators taking matters into their own hands with additional laws & regulations that may keep worthy individuals from receiving a valuable privilege. Take home medication is so very beneficial to honest, hard-working individuals in recovery. It frees them to seek employment, hold a job, care for family, and to more easily meet many other important responsibilities in their lives.

Balancing Methadone Client Rights With Accountability

methadone-clinic-13Methadone “take home” medication (also referred to as “take outs”) is a true convenience for those enrolled in a methadone clinic. Typically, clients who demonstrate that they are drug free and progressing in their substance abuse treatment can earn the privilege to receive take home medication.

Receiving take home methadone requires that the prescribing physician (and clinic) have safety and accountability measures in place to help reduce the chance of methadone or suboxone getting into the wrong hands. When clients take medication home, it is critical that the opioid replacement medication be kept secure and out of the reach of children. Overdoses can occur with individuals that have no developed tolerance to opioid replacement medication.

Receiving take home methadone is a privilege, not a “right”. This decision to award take home medication is usually a collective decision made among the clinical and medical staff in a treatment program. They base a client’s readiness to receive take home medication on that person’s level of recovery stability, absence of active psychiatric symptoms, and the safety & security of their immediate home environment.

Methadone and suboxone have considerable “street value” and can be resold or misdirected. Therefore, clinic staff want to be as assured as possible that any particular client receiving methadone is sincere, stable, and appropriately focused on his or her own recovery.

Methadone and suboxone patient rights are of course always very important. Clinics and physicians sometimes walk a fine line between accommodating the patient and requiring accountability measures that are perceived by the patient as a hassle. For example, methadone clinics are required to perform random “call backs” in which a client is contacted and required to bring their methadone medication back to the clinic within 24 hours for a recount. This helps the clinic insure that the patient is not over-taking their medication or misdirecting (selling) their medication. While not a guarantee of good behavior, it does encourage patients to treat their take home medication responsibly and with substantial care.

Another safety measure is random urinalysis. It is not safe for patients to receive take home medication if they are using other unapproved drugs. If a random drug test shows the recent use of illicit substances, then this requires the clinic to suspend take home privileges for some period of time, at least until it can be established that the patient is back on track and testing drug free again.

If a patient feels that their rights have been unfairly compromised, then they have access to the clinic’s internal review process and/or the state’s methadone board who hear and investigate client grievances. In the end, the patient and the methadone clinic should be in a cooperative partnership. This is the working ideal in any health care relationship one has with their treating physician. Clinics exist to treat and serve patients, and opioid addicted patients need the services of opioid treatment providers. This relationship is extremely valuable and should be nurtured by both parties both at initial intake and ongoing for the duration of the treatment process.

Anti-Methadone Sentiment Not Rooted in Reality

methadone52In browsing articles on current methadone treatment, I came across a brief one in the United Kingdom’s Daily Record specifically from the Scottish news section. The article contained a number of derogatory quotes (in regard to methadone) from Scotland’s Maxie Richards. Ms. Richards runs a foundation for addicted people in recovery.

One quote from Ms. Richards pertaining to methadone included: “To me it represents a hopeless road, a road to nowhere.” Another comment was “I think it is such a waste to let young people spend years on methadone because we don’t think there’s any hope for them.” Ms. Richards is openly critical of the government’s support of methadone treatment programs.

Her words “a hopeless road” are not a fitting description of the life enhancing benefits of methadone in treating addiction. To the contrary, methadone is often the single most beneficial intervention for someone struggling with opioid addiction. In my experience, any addiction professional who is categorically against methadone is revealing a lack of education on evidence-based treatments, and is merely expressing an unsubstantiated personal bias that is easily refuted.

Today, a former client made a surprise visit to our clinic. She had been in methadone treatment with our agency for a little over 4 years and had come off of methadone one year ago. Today, standing in our lobby, she was full of life, smiling, and enthusiastically talking about how well things were going in her life. She said that methadone had been instrumental in saving her life. Since leaving treatment, she had remained completely drug free, was full-time employed, enjoying positive relationships with her family. And she looked wonderful, very healthy, and had a beautiful complexion.

Was her methadone treatment a “hopeless road’? Absolutely not! She, and we, knew that it was a bridge to a better life. She had originally arrived at our clinic beat down, lost in addiction, hopeless, and desperate for an answer after having tried everything she knew of to get clean and sober. Choosing methadone and counseling worked for her. I wonder what Ms. Richards might think if she had the chance to see and to speak with our former client today? Results speak for themselves. Methadone programs save lives and provide a deeply desired new opportunity. True, not all methadone programs are the same. Some are better than others.

Hope … is what many addicted people find when they begin dosing with methadone. Relief … from painful opioid withdrawal symptoms is what they feel. Gratitude … is what they express for a new start in life. And eventually happiness. Which is what our former client had come to share with us on this day.