How to Avoid the Methadone Trap

2. A patient in my office for addiction treatment once stated:“When I started at the Methadone clinic; another patient told me, ‘Say good bye to the next 5 years of your life’. That was 5 years ago!”. This quote provides insight into a problem with addiction treatment centers. Many people are aware that Methadone treatment involves daily visits to clinics. I have had many patients complain about clinics not responding to their desire to taper and or having their dosage rapidly increased. The longer a patient stays “in treatment” the more profitable it is for the clinic. Note the following quote from the American Society of Addiction Medicine: ‘…Equally as important, recommended dosages of methadone and Buprenorphine when used to treat addiction involving opioids differ from recommended dosages for pain treatment. The ASAM National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use notes that, while a relatively low dose of methadone (e.g., <30 mg per day) can lessen acute withdrawal, it is often not effective in suppressing craving and blocking the effects of other opioids.viii Most patients fare better if their initial 30–40 mg per day dose is gradually raised to a maintenance level of 60–120 mg per day. Indeed, multiple randomized trials have found that patients have better outcomes, including retention in treatment, with higher doses (80–100 mg per day) than lower doses.

3. Regarding Buprenorphine, the ASAM Guideline recommends that Buprenorphine doses after induction and titration should be, on average, at least 8 mg per day. However, if patients are continuing to use opioids, consideration should be given to increasing the dose by 4–8 mg. The US Food and Drug Administration (FDA) approves dosing to a limit of 24 mg per day. There is some evidence regarding the relative efficacy of higher doses. Converting these recommended dosages to morphine milligram equivalents (MME) (also known as morphine equivalent units (MEU)) reveals that they exceed the CDC recommendations regarding MME for chronic pain. The recommended 60-120 mg of methadone per day becomes 600 –1,440 MMEix; the recommended range of 8-16mg Buprenorphine becomes 80-160 MME.” MME or Milligram Morphine Equivalent is a conversion factor used to convert between opiate medications. Above it is noted that the MME for Methadone is 5 to 10 times greater for Methadone to obtain the same desired effect! Using the lowest dose of medication has the less potential for harm to a patient in the long run. During my experience in treating opiate addiction several questions have come up: Why would a patient choose to make daily visits to a Methadone clinic when they can have weekly or monthly visit for Buprenorphine?

4. 2) Buprenorphine is recommended to be started when a patient is at 30-60 MME of an opiate. So, doesn’t the rapid induction and increasing of Methadone dosage to a high MME (above 60 MME as described above) prevent or deter conversion to Buprenorphine? 3) Does the goal of keeping a patient “in treatment” lead to a conflict of interest? 4) How does one determine if their clinic is keeping them on a high dose of Methadone to prevent the patient from leaving the clinic? 5) Does a counselor at a Methadone clinic serve a patient or maintain the patient “in treatment” for the clinics monetary gain? 6) Why don’t Methadone clinics report to the prescription monitoring data base? Doesn’t this create risk of patients diverting the opiates while they are in treatment? The above questions are difficult to answer with certainty. However, one can certainly see that there is a potential for a conflict of interest between the patient’s health and the clinics profits.

5. In my Marietta addiction center, we offer Buprenoprhine (Suboxone, Subutex and Sublocade) as a Methadone alternative. These medications offer the flexibility of weekly to monthly dosing. We refer our patients out to outside counselors to avoid conflict of interest.TheBuprenoprhine dosage used has a lower MME than patients commonly using Methadone therapy. Many new patients presenting to our Suboxone treatment center ask about how long they will need to be in treatment. My standard answer:“It will be more than six months but I am not going to extend in out for 6 years. Having said that, there are people who need to be on therapy for extended periods. The goal is to use the least amount of medication necessary as all medicines have the potential to damage internal organs with long term use.” In addition to addiction treatment with Suboxone, our office also is able to use the NADA acupuncture protocol for addiction. As a licensed pain management clinic we treat pain primarily with acupuncture and physiotherapy. Our goal is to have patients “pain free without pills”TM. This includes having patient free from the pain of addiction. With our pain management patients, we ALWAYS use the smallest dose of opiates possible to treat pain. We introduce all of our patients to acupuncture with one FREE treatment. Why the FREE acupuncture treatment? To demonstrate to patients that there are other means to treat pain other than pills. Remember our goal: “Pain Free Without Pills“TM.

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