The Methadone Filing Cabinet
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Dear Doctor
A Letter for Methadone Patients to Carry With Them When Seeking Medical Services
by J. Thomas Payte, M.D.
The bearer of this letter is a patient in a methadone maintenance treatment program. Methadone patients frequently need
treatment for other medical, surgical, and dental conditions. At times the health professional is not familiar with
addictive disease and the various forms of treatment, including maintenance pharmacotherapy using methadone or LAAM. The
reaction to being informed about the addictive disease/methadone treatment often includes fear, anger, prejudice,
disgust, and other negative subjective responses, none of which contribute to the objective delivery of quality health
care. Many patients are very reluctant to provide information to the other health professional about their addiction and
treatment with methadone or LAAM because of previous unpleasant experiences. The most common reaction is based on fear
which is inversely proportional to the professional's level of familiarity with addiction medicine and patients with
addictive diseases. The purpose of this brief letter is to touch on the most common problems encountered and to offer
any assistance I might be able to provide. It is widely accepted that addictions are diseases and that their treatment
is a legitimate part of medical practice. Addictive disease can be characterized as a chronic, relapsing, progressive,
probably incurable, and often fatal (if untreated) disorder. The principle diagnostic features are obsession, compulsion,
and continued use despite adverse consequences (loss of control).
Methadone has been used in the treatment of opioid dependence for 30 years. It has been found to be both effective and
safe in long term administration. An adequate individualized daily dose of methadone eliminates drug craving, prevents the
onset of withdrawal, blocks (through complete opiate cross-tolerance) the effects of other opiates, such as heroin or
morphine. Efficacy of treatment is based on elimination of or reductions in illicit/inappropriate drug use, elimination
or marked reduction in illegal activities, improved employment, pro-social behavior and improved general health. Such
treatment has been shown to be effective in reduction of the spread of HIV and other infections. Dramatic reductions in
mortality rates are seen in methadone maintained patients in comparison to untreated addicted populations.
The methadone maintained patient develops complete tolerance to the analgesic, sedative, and euphoric effects of the
maintenance dose of methadone. Tolerance does not develop to the effect of preventing the onset of withdrawal syndrome.
Methadone has a half-life in excess of 24 hours which makes single daily dosing possible. Methadone has a relatively
flat blood plasma level curve that will prevent the onset of abstinence syndrome for over 24 hours without causing any
sedation, euphoria or impairment of function.
Second to discrimination, the management of pain in a methadone maintained patient is the most common problem we
encounter. Since the patient is fully tolerant to the maintenance dose of methadone no analgesia is realized from the
regular daily dose of methadone. Relief of pain depends on maintaining the established tolerance level with methadone
and then providing additional analgesia. Studies have shown that exposure to adequate doses of narcotics for the relief
of acute severe pain does not compromise treatment of the addiction. Nonnarcotic analgesics should be used when pain is
not severe. In the event of more severe pain the use of opioid agonist drugs is quite appropriate. The dose of opioid
agonist drugs, such as morphine, is usually increased to compensate for the opioid cross tolerance established by the
methadone. Also, the duration of analgesia may be less than usual. Doses must be individually titrated to ensure adequate
analgesia. Best results are obtained with a scheduled dosing as opposed to PRN. Morphine may be required q 2-3 hours at
whatever dose that provides relief.
There is no justification for subjecting a maintenance patient to unnecessary pain and suffering because of their disease
or its treatment. Adequate treatment of pain will ensure a more pleasant hospital stay as well as enhance healing and
recuperation.
Opioid partial agonist and agonist/antagonist drugs such as Buprenex, Talwin, Stadol, and Nubaine should never be used in
the methadone tolerant individual. Severe opiate withdrawal syndrome can be precipitated by drugs of this type.
Both propoxyphene and meperidine are known to produce CNS excitatory metabolites. Due to the cross tolerance the higher
doses required to achieve analgesia can increase the risk of seizures. For this reason propoxyphene and meperidine should
be avoided in the maintenance patient.
The administration of opioid agonist drugs should be closely supervised in terms of quantities and duration. Prescribing for
self-administration by the patient should be carefully monitored. If it is necessary to prescribe for self administration,
caution should be exercised in the amounts prescribed and refills carefully supervised. Similar precautions are indicated in
the prescribing of sedative/hypnotic and CNS stimulant drugs. The abuse potential of ALL benzodiazepines is quite high.
At times the attending physician is tempted to treat the opioid dependence itself. This is usually attempted by tapering the
methadone dose to zero. If successful, the graded reduction may result in a reduction or elimination of the physical
dependence but has no effect on the disease itself. Even after the methadone is discontinued significant signs and symptoms
of abstinence may persist for several weeks and even months. The relapse rate associated with detoxification alone
approaches 100%. A relapse to street/illicit drugs increases risk of overdose, hepatitis, AIDS, and a host of other
biomedical, psychosocial, legal, and other complications. Under some circumstances some form of intervention can be
accomplished during a hospital stay for other conditions when desired by the patient and in consultation with the methadone
program physician. Such a process should involve experienced addiction professionals with a strong emphasis on continuity of
care upon discharge. If you have any questions or concerns about our mutual patient in relation to methadone or drug
dependency please call me. I would be delighted to hear from you.
Sincerely,
J. Thomas Payte, M.D.,
Medical Director
and a Certified Member of the
American Society of Addiction Medicine
Drug Dependence Associates
3701 West Commerce Street
San Antonio, Texas 78207
Phone: 210 434-0531
Fax: 210 434-0321
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