Wednesday, August 11, 2010

Methadone Carries

Methadone is dispense daily by the pharmacist in a liquid, often a tang orange juice. Methadone is witnessed taken in this manner so that it doesn't get diverted to street sale or use. Because of the limitted 'window of safety' it is a very unsafe drug of abuse. Overdose and respiratory depression happen easily. In the methadone patient the person is started on a safe dosage and titrated up weekly to where they have sufficient medication on a daily basis to block the endorphin receptors and take away craving and/or withdrawal symptoms. This daily dosage might well be 2 to 3 times a safe dosage for a person who might otherwise take methadone 'to get high'.

Because of the potential danger of methadone, Methadone carries are a privilege given to those who are stable and demonstrate that they are no longer abusing drugs but rather following the medical regimen for methadone.

A "carry" refers to a daily dose of methadone mixed with Tang and dispensed by the pharmacy but which is allowed to be taken home. "It is recommended that carries not exceed 4 days or 400 mg, whichever is less".

To obtain carries a patient must demonstrate social, cognitive and emotional stability as evidenced by keeping appointments, attending pharmacy, improved social relationships.

The urine drug screens must be free of all mood altering drugs for a minimum of 12 weeks.

Methadone must be stored in a safe and secure place and patients must be aware of the danger of methadone to others, especially children.

Carries are not appropriate for patients who do not have safe, supportive housing.

The doctor is required to state the reason for giving the carries. Examples are for attending school, work, caring for young children, or travel.

Carries are started on a one day carry and increased on a monthly to two monthly schedule to twice weekly pick up with the first dose being witnessed at the pharmacy. During this time patients must still be seen regularly and given random urine drugs screens for methadone metabolites and illicit drugs.

Patients who become unstable must be reassessed. Evidence of instability is return to use of mood altering drugs, eg benzodiazepines, cocaine, alcohol, marijuana. Also one must consider if a previously adequate methadone dose becomes inadequate this might indicate diversion. When methadone is reported lost, spilled, stolen or vomited it is always suggestive of diversion. Patients who become unstable must return to daily witnessed ingestion.

Since 'carries' are a privilege and reflect a stable methadone maintenance program the presence of 'carries' reflects well on a patients progression in the program.

As methadone primarily addresses opiate dependence it is not uncommon for patients on methadone maintenance to continue to abuse other drugs especially early in treatment. This does not suggest the methadone maintenance program is a failure. Methadone maintenance reduces IV opiate use and illegal activity associated with heroin dependence. It also results in stabilization of housing, income, development of supportive relationships, and stable mental and physical health. These can all contribute to long term abstinence from other opiates and mood altering drugs. This can all lead to confidence and motivation to wean off methadone.

Reference: Methadone Maintenance Handbook, College of Physicians and Surgeons of British Columbia, 2005
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