Sunday, March 24, 2013

Methadone Maintenance Therapy and Benzodiazepines

Methadone Maintenance Therapy is the the harm reduction treatment for opiate dependence. It can be used for IV Heroin users or opiate pill takers or those who smoke opiates.  These are commonly purchased on the street.  Oxycontin, so called hillbilly heroin, was a commonly diverted opioid prescription that was withdrawn and replaced by oxy-neo, a form of the the same medication which comes in a delivery system which resists crushing for illegal injection.
Benzodiazepines are a large class of pharmaceutical preparations with many benefits and even life saving potentials.  They are used for the treatment of seizures, sedation, panic attacks and insomnia, just to name a few of their more common uses.  The most known of these is Diazepam, known by it's most common trade name, Valium.  Other common benzodiazepines go by the following names, ativan, lorazepam, clonazepam, rivotril, temazepam, etc.  These were all meant for short term usage, in the range of weeks to at most a few months.  Because of their high effectiveness and benefits they tend to be continued increasingly for psychological rather than the physiological benefits.  They have abuse potential and its common over months to a year of use for people to become dependent on them and chemical dependence can lead to addiction.
Further, it's been recently found that benzodiazepines interfere in the healing of the brain from acute trauma.  They are used most carefully in patients with head injuries and studies suggest that those who had strokes who were on benzodiazepines of any kind were least likely to recover completely from strokes. So here is a potential scenario where a person has a cerebral vascular accident loses the capacity to talk and walk, only to completely heal so that a year later they are back to normal. In contrast a person using benzodiazepines might experience the same brain condition only never get out of bed again, needing life long nursing care, bedridden for life.
The College of Physicians and Surgeons of BC has been carefully following the research on benzodiazepines and noted that those who died on methadone maintenance therapy were commonly taking benzodiazepines. One of the most significantly negative side effects of benzodiazepines, like valium, lorazepam and rivotril is that they depress the respiratory rate, making breathing shallower and slower.  When patients take Methadone they can also lose their alertness if the dosage is not yet correctly established.  Combined a person stops breathing and doesn't know it and doesn't wake up.
The College has been warning about the dangerous combination of Methadone Maintenance Therapy with the use of Benzodiazepines but this last week issued a position paper suggesting they were indeed contraindicated.
This is extremely helpful for clinicians in the front lines and shows that those at the College of Physicians and Surgeons are understanding of the basic plight of the practitioner.  I've had my life threatened many times for refusing benzodiazepines.  mOne of my patients who was on a benzodiazepine 'taper', slowly coming off an extremely high dose of benzos told dozens of people he was going to 'shoot Dr. Hay'.  He occasionally brought a gun to the office and showed me what I was facing.  He was actually a fine fellow just having a little difficulty coming off benzos.  More commonly a woman would threaten the doctor with sexual harassment as is common in our community where people marginalized almost dehumanized  will use whatever tools or weapons they have to get what they deem they need to reduce their obvious suffering.  This is unfortunate because these poor souls then get utilized by the downright evil machinations of others who will seek to profit from championing any cause.
So it's really appreciated when the College of Physicians and Surgeons of BC is indeed proactive rather than a 'monday morning quarterback', as commonly seen in beaurocracies which so easily move towards Mandarism unless checked early.
I have patients who are on 6 mg of clonazepam, the normal dose being only 2 mg a day and 4 mg being excessive. They argue threaten, throw tantrums, shout, scream, disrupt the clinic when I reduce them by .125.  It's like asking an alcoholic drinking 60 beer a day to go down to 59 or asking a 4 pack a day smoker to forego 3 cigarettes.  These people are already struggling with addiction, including, heroin, crack, nicotine or cigarettes, alcohol and we in the methadone maintenance services are not the ones who have made a fortune off the patients selling them all this stuff and being the 'good bartender', 'good drug pusher' or  'good doctor' who gives them candy.  Addiction Medicine doctors are the most maligned doctors on 'rate your doctor' services the world over.
So thankfully this week I can now point to a piece of paper and say 'this is the law', see, 'don't kill the messenger', we have to get you off this stuff slowly or I'll have to not prescribe it for you at all.  I've had a dozen complaints to the college directly and indirectly by patients who I've refused.  Thankfully the College has people who have worked in the front lines and know beyond a certainty that there is no 'nice' way to say 'no' because 'no' is 'no' and to severely disturbed addicted psychotic patients 'no' means 'yes'.
What they do understand is, "I will lose my job if I prescribe you more ativan" or "It's against the law for me to prescribe you rivotril".  "You told me you can buy a 10 mg valium on the street for $10, well if you want me to supply you valium at that rate, I can't. Somebody is doing bulk and I'd have to charge you $100 or $1000 a pill to justify the personal risk I'd be taking and I don't think you can afford that.  I think what you want is a dirty pharmacist or a doctor who has already lost his license. "  We can have reasonable discussions like that but saying that 'benzodiazepines are unhealthy' to a person who is walking dead already, having overdosed many times on drugs and willing to do anything to stop the pain, simply doesn't 'cut it'.  Frankly there are  too many 'silly' people out there who don't know anything about addiction or addicts or the real world outside their ivory towers and well protected neighbourhoods.  Their smug judgementalness is only comparable in stupidity to their indifference to the human condition.  We're all in this together.  It's time we really did make a difference rather than just spouting platitudes and pointing fingers.
Several of us addiction medicine doctors got the College report and almost danced together.  Only last week we'd weaned a methadone patient off clonazepam and they'd gone to a leading local psychiatrist who'd given them 6 mg clonazepam on the first visit.  Thanks to the College our colleagues who avoid working with addiction , and certainly don't have methadone patients, will be aware of the potential life threatening combination and think twice before cavalierly prescribing addictive and dangerous medications to patients with alcoholism and addiction. Hopefully too people will do more thorough histories. In BC there's the pharmanet too which allows doctors to learn what patients are on, because in fairness to doctors, psychiatrists especially,  addicts and alcoholics are 'cunning, baffling and powerful'. When they want drugs from a doctor they're not likely to be upfront with him about their history of abuse and addiction.
I don't want patients to die on my watch. I work with methadone patients because it's an area of greatest need  Addicts are society's 'bitch', to coin a jail term. I like to see patients crawl back from the grave and walk into the light. It's an exhilarating area of work.  I talked to an oncologist and we shared our joy in the thrill of winning against all odds and curing the incurable.  It's a whole lot more fulfilling than treating the common cold or saying 'there, there' to a person having exam anxiety.  All of this is important and in my earlier years I did all of that but today my greatest joy is seeing patients get on in recovery.  I've seen patients get on methadone and eventually have carries, so they can be trusted with their methadone like any patient with a chronic illness.  Some stay on methadone but get their lives back, go to recovery meetings, attend doctors appointment, take care of their health, return to work, and reestablish relationships with their families.  Some get stable on methadone and after a year or so taper off and go on to be wholly abstinent from mood altering drugs in NA and AA 12 step programs, some joining churches or temples or synagoges, and reconnecting with community.  Many do volunteer work.

It's really rewarding too to know that the Minister of Health and the College of Physicians and Surgeons of BC are there understanding and helping front line clinicians do their job.

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