Wednesday, March 17, 2010

Methadone Maintenance Therapy

I first came across Methadone Maintenance Therapy in my Community Medicine residency in the early 80's. As part of my formal training I studied the effects of methadone maintenance in Europe. It was obvious there that people who were IV heroin users with increasing difficulties benefitted greatly from the stabilization offered by methadone. Their individual health improved because they did not have to invest so much of their time in seeking money to meet the needs of their habit.

Addiction has been called the great 'eraser' because it takes so much out of one's lives, the friends, work, assets and eventually all pleasure. People in the end are using just to feel.

On the methadone programs patients began to keep appointments, care about their health and appearance, take pride in accomodation, and often return to work. For many methadone maintenance was a stepping stone to abstinence programs. (see "comment" regarding this.-WH) It was a community medicine program and the benefits for the community were as great as for the individual.

Heroin is a principal source of revenue for criminals, especially those in organized crime. The money doesn't go to churches or hospitals or schools. It supports those elements most actively antisocial. Increasingly heroin trade has been a source of revenue for terrorist organizations.

Individually a heroin addiction can cost $100 to $200 a day. Given that a rule of thumb for theft is that the thief only gets 10 cents on the dollar, those who steal to support a heroin addiction, need to steal $1000 to $2000 daily, 365 days of the year, meaning a cost to the community from crime of roughly $400, 000 to 800,000 a year. Once a person is in a methadone maintenance program even if they use a 'little' they are not a principal supporter of the criminal element. Freed from their dependence on the criminals and what the criminals want, patients on methadone maintenance can participate in programs, address psychiatric and physical health needs, get education, and job training.

Because of the spread of disease through IV use, especially sharing needles, and generally poor health care and association with criminals, methadone maintenance programs serve the community by dramatically reducing the spread of infectious disease.

As a psychiatrist I saw many individual patients on methadone maintenance observing their progression of horrendous chaotic lives back to something resembling normalcy. It was obvious that methadone was beneficial for these patients.

Later I formally trained in the use and history of methadone for my Addiction Medicine subspeciality examinations. As an addiction medicine specialist I saw heroin addicts but mostly worked with those whose illness was not so far progressed. They were able to enter abstinence based programs like narcotics anonymous whether or not they used methadone as part of that transitional process.

Finally I took the British Columbia Methadone training and preceptorship. I was most impressed with the course materials and course. The preceptorship was excellent and the College staff were extremely helpful. On one hand I thought I was very qualified when I entered this process but at the same time was amazed at the hands on information that simply isn't covered in courses or text books. I'm still learning. Working in a methadone maintenance clinic I see the improvement in peoples lives and admire the doctors, nurses, counsellors and staff for their committment to the health care.

When I've told people that I work in a methadone maintenance clinic I've been interested in the responses. First off, there's been that stigma that's attached first to the heroin users, and secondly those with illnesses associated with heroin use, hep c and HIV. Even though people who knew I worked in addictions somehow considered the 'methadone clinic' as a less 'savoury' place. Stigma that's attached to a disease is also attached to the caregivers.

When I left family medicine for psychiatry there was tremendous stigma. I remember being told "You're a top doctor. You were in a surgery residency. You don't need to work in psychiatry." When I subspecialized in addiction psychiatry I heard it all again, even from psychiatric colleagues. "You've got a great psychiatry practice, why would you want to make trouble for yourself by treating alcoholics and addicts." Finally, "what's a nice guy like you doing in a place like that" goes with the move to methadone.

For one, I like the other doctors who work here. I've known them for years through referrals and individually and they're the other end of the stereotypical 'cosmetic surgery' hollywood doctor. I'm in good company that is. But the patients are stigmatised. If health care is about helping people who are most unhealthy then this is where the rubber meets the road.

Gabor Mate wrote so well about some of the indivdual patients in his recent book, In the Realm of Hungry Ghosts. "There but for the grace of God, go I." None of these people decided when they were born that they wanted to end up with a heroin addiction but they did. In the Methadone Maintenance Program they're taking action to get healthy and return to society. They're amazing survivors and their motivation is tremendous to see.

Others have asked me why methadone needs to be controlled. Only weeks ago friends told me about a young kid who was given methadone at a party. Because its such an unpredictable drug he died with his first 'hit'. It's a controlled substance because it's dangerous and we are taught very well to be very careful about iniating treatment. As doctors we work with a lot more dangerous drugs than methadone (heart meds, insulin, some psychiatric meds, etc.) and in our care methadone is properly administered with the least possible risk.

Diversion is where a drug goes out of the program where it is supposed to be used and ends up being sold on the street. Because of the danger of the drug all of the training and 'control' is in place to prevent it's misuse. Despite all of this, kids at parties get given methadone, possibly stolen, and die.

Most methadone is dispensed in pharmacies with the dispenser observing that the medication is taken on site. When people are well stabilized and have established their trustworthiness they are allowed to take a small supply, at most a few days, away with them to allow for weekends away for instance. This is where methadone can be stolen and diverted.

Methadone is also an amazing pain medication and used in cancer treatment for one. The patients receiving methadone for pain have more freedom with prescriptions and it is these patients whose methadone can also be diverted especially those endstage where friends, relatives or care givers can take the medication more easily.

All the checks there are for the best. The Health laws in this regard are really wisely considered.

People then ask if methadone doesn't interfere with people becoming abstinent from drugs and alcohol. It's not the 'first' line of treatment. Intake goes through trials at quitting in detail. The Intake sheets for assessing a person's appropriateness for methadone treatment are extremely well thought out and refined. There's none of the stupidity that went with "Reefer Madness". Medical doctors treating a medical illness with a medical treatment are doing so with the greatest concern for the individual and the most serious concern for the community. The agencies in place for the reinforcement of the protocols are doing their best too.

Methadone for so many is the last hope. The big book of Alcoholic's Anonymous was going to be called 'a way out'. Someone else had used the title so the book and organization became AA. For so many methadone is just that , a 'way out'. It may not be the last step but it's certainly a very commendable first step. It's certainly going in the right direction. And that alone says a whole lot for it.


Anonymous said...

Thanks for your insightful post.

I did want to point out one thing--something the vast majority of lay people, and many of those i n the field of addiction medicine, fail to recognize about MMT. It is commonly seen as a legal substitute for heroin--not "real" recovery, which must be demonstrated by total abstinence from drugs--but maybe a step in the right direction that helps to stabilize lives. It seems that you may perhaps share some of that bias--most do, as I mentioned.

However, what many fail to understand is the brain chemistry issues that follow long term opioid addiction--the cessation of the brain's endorphin production, for example. For some this is a short term cessation that will resume in time as they become abstinent. For others, it is permanent. These folks suffer from severe anhedonia, depression, exhaustion, irritability, etc when they become abstinent, and this is not relieved by time as with some. For this group, long term MMT is a medical rebalancing of the brain chemistry, allowing them to feel normal again and to function productively.

Relapse rates for those leaving MMT are about 90%--however, success rates for those who remain IN treatment are higher than with any other modality. Yet patients are driven from MMT every day by well meaning loved ones and even by clinic personnel who urge them to "get off that stuff" and "get into REAL recovery". This results most often in relapse and many times in tragedy. These patients are urged to attend 12 step groups, then rejected by these very groups as being in "active addiction" for being on methadone. The patients feel confused, their pride at doing well starts to decline, their shame at being on methadone, rather than being relieved by education, grows through ignorance and prejudice.

Please, help your patients to know that recovery is not about what medications one does or does not need, but instead, by the fruits of one's life--are they productive, responsible, reliable, honest, happy? The need for medication to rebalance brain chemistry is NOT the same as addictive abuse of a drug. Patients need to understand the difference between addiction and physical dependence, and to be empowered against myths like "trading one drug for another" and "liquid handcuffs".

I am a MMT patient in the USA. I have been on MMT nearly 6 years. Prior to that I spend almost 20 years addicted to Rx opiates. I went through 13 abstinence based rehabs, to no avail. Methadone saved my life, and returned me to a fully functional existence. I now attend the clinic once a month and receive 27 takehomes. This enables me to live a normal life, like anyone else on a long term chronic medication, rather than attending a crowded, noisy clinic for hours on a daily basis.


haykind said...

I love your comment and thank you for adding it to this blog.

I know about the research you're referring to. It's really the same with thyroid replacement. We sometimes have to give people thyroid supplements but when we go to take them off the thyroid has shut down and may not start up again. This happens with lithium on occasion. Maybe if we could wait long enough the thyroid would 'reboot' but in reality we don't and it doesn't. The risk of heart disease and other consequences of untreated hypothyroidism simply make adding thyroid solution.
The same has held true for people with opiate treatment, a few, and this isn't just with methadone but also with opiates for pain relief.
Replacement therapy isn't really that 'new'. Insulin in diabetes is replacement therapy.

The other issue of what is "recovery' comes up with one of my closest friends and one of the most 'spiritual people' I know. He required opiate therapy for chronic central pain and I asked him how this affected his prayer life and connection with God. He said it didn't. I believe him. He's not 'abusing' opiates but taking 'medicine' as directed.

Dr. Ray Baker did methadone maintenance here and is a really fine Christian too so I discussed it with him as well. He was the one who told me about the people who literally had shut down their pleasure centres and needed lifetime replacement, I think we'll soon get goodfMRI and PET scan data on this. Davidson's lab has done cutting edge Amygdala research in the Wisconsin imaging lab so hopefully one day I'll have some up to date references. I'm planning on searching this out now that you're reminded me of it and hopefully will be able to add it on one day.
AA hasn't had this problem and lots of the mmt people have found a home there. It's more commonly an issue in the NA groups. I've even got some people on long term benzodiazepine "maintenance"after alcohol abstinence and they're doing just fine in AA. My alcoholic with severe pancreatic disorder who if he drinks will die smokes pot and I've written the letter for his 'maintenance' pot and encourage him to go to AA. He's still planning on stopping and I just tell him what ever keeps him from drinking I support. Abstinence is great but it's not the only way. Certainly that was the position of the first AA folk. But then AA only requires a 'desire not to drink'. So if MMT don't drink and want to do that program they're welcome and my patients who do had alcohol along their road. I've had the "pure" heroin addicts though and their first drug was heroin andthat's the only drug they've used.
It all makes "prevention" and 'early intervention" look attractive too.
Thanks again for your incredibly valuable comments.

Fawad Tariq said...

Maintenance pricing is a percentage of the SRP of the product for which maintenance is being purchased for the first twelve months typically around 20.Maintenance ProgramsMaintenance will always be quoted as a percentage of SRP rather than of netor purchase price. Purchasing twenty-four months of maintenance and support is a better option from a pricing standpoint,if you would like the longer term coverage. Pricing for maintenance terms beyond twenty-four months will be provided upon request.