Methadone Treatment: Common Questions, A Common Answer

As someone who has visited and consulted with methadone maintenance treatment providers in many countries of the world, I have been struck by the universality of the questions that are posed regarding various aspects of clinical management. Practitioners seek guidance with respect to dosages, duration of treatment, patient non-compliance, etc.—and, significantly, uncertainty is voiced both by those with experience in the field and others who are contemplating involvement. My standard answer to all these questions is the following: Be guided by the same considerations that you would apply when confronted by these issues in the care of any other patients, with any other disease, treated with any other therapeutic regimen.

One might wonder why physicians have a different mind-set with respect to methadone maintenance than that which guides them in other clinical fields. I believe the answer is to be found in the fact that politically, bureaucratically, legally and economically methadone is, and in most countries always has been, treated in a unique manner; no wonder, then, that when it comes to clinical issues physicians too view the prescribing of this medication as “different,” and hesitate to apply a common orientation. And yet, as stated above, that is the surest way to arrive at appropriate answers. Let me illustrate with some specific examples.

QUESTION 1: How dangerous is methadone?

As with all other medications—even such common household products as aspirin—methadone is dangerous, and can even be fatal, if it is used by those for whom it is not intended, or if it is inappropriately prescribed by the physician or taken by the patient.

QUESTION 2: For whom should methadone be prescribed?

As with all other medications, methadone should be available to any patient whom the physician believes is likely to benefit from it, and who voluntarily accepts it. There are no concomitant illnesses that preclude methadone, and it is irrational to demand of patients that they first “fail” with other therapeutic approaches, survive a specified number of years of dependence or reach a certain age, or meet other arbitrary and unprecedented criteria for “eligibility.”

QUESTION 3: What is the optimal maintenance dose of methadone?

As with all other medications, there is absolutely no place for moral judgements that particular dosages are inherently “good” or “bad.” There are general guidelines, based on empirical and scientific evidence as reported in the professional literature, regarding the dosage range associated with optimal results in most patients. For methadone, this range is approximately 80-100mg per day. However, as with all other medications, the ultimate decision as to dosage must reflect the physician's assessment of the individual patient's response, and some will be found to require a higher dosage, and others lower. (NOTE that “maintenance” dosage must be distinguished from the amount of medication to be prescribed at the outset of treatment. Here, as with all other medications, one must follow the admonition: primum non nocere. We know that dosages above 40mg can lead to fatal outcome in non-tolerant individuals, and thus—to rule out even a remote chance of risk to the patient—one should give no more than 30-40 mg. initially and raise the dosage in increments no greater than 10mg twice a week.

QUESTION 4: How long should methadone maintenance be continued?

As with all other medications, methadone should be continued as long as it is effective and does not cause significant side effects, and as long as there is reason to believe that its termination would be associated with risks to the patient. Since methadone does not “cure” patients (a limitation that is true of virtually all treatment of chronic illness and, unequivocally, of all other therapeutic modalities in the field of addiction), the safe and conservative approach is to continue maintenance indefinitely.

QUESTION 5: What “supportive” services should or must be provided?

As with all other medications, methadone prescribing ideally should be accompanied by a range of services for concomitant medical, social, legal and other problems the patient may have. Optimal care of the diabetic involves more than simply prescribing insulin; high blood pressure may be controlled with appropriate anti-hypertensive drugs, but for greatest therapeutic efficacy patients should be offered assistance and guidance in exercise, stress reduction, diet, etc.; care of the seriously ill cancer patient is not just a matter of administering drugs, but providing extensive support to the patient, family members and loved ones; etc. On the other hand, as with all other medications, it is wrong to make availability of such services a prerequisite to offering life-and-death medical care to the opioid addict, and to threaten termination of treatment when patients fail to accept and utilize the “support” that is offered.

QUESTION 6: What is the role of urine tests?

As with all other medications, the most effective use of methadone may require a variety of laboratory tests. The frequency of such tests, however, and even more importantly, the conclusions and consequences to be drawn from the results, must be left to the individual clinician. Certainly, it is absurd (though tragically common) to make unfavorable test results grounds for terminating treatment; this is analogous to punishing by termination of care the epileptic who continues to have seizures, the cardiac patient whose angina persists, the diabetic whose blood sugar concentration remains elevated, etc.

QUESTION 7: What should be done to/for the “noncompliant” patient?

As with any other medication, compliance by patients with the treatment regimen is a major challenge for the clinician (this should be no surprise, since anecdotal evidence suggests that physicians are among the least compliant of all patients!). There are no easy responses—but threats of “punishment” are rarely either ethical or effective. Patience and persistence in seeking to overcome (or at least lessen) noncompliance are essential, and among the most important attributes of any successful doctor.

Conclusion

Optimal treatment of opioid dependence will never be achieved as long as it is subject to standards, restrictions, controls and clinical orientation that would be unthinkable in other areas of medicine. Of course, like everyone else, physicians would like to have clear answers to the endless variety of questions they confront in the course of helping their patients. Alas, few problems in life—and virtually none in medical practice—are “simple.” However, those responding to the disease of addiction will find it helpful to have a single guiding principle—namely, to approach the challenges in this field in a manner consistent with that applicable to all other areas of medicine.

A final observation regarding the commonality between methadone maintenance and all other medical care regimens: Providing treatment for the opiate-dependent individual is difficult, but it is also a very great privilege (and enormously gratifying) to be able to help those who want and need care, and may well die without it!