1. Methadone is a medication used to treat opiate dependence
3. Opiate dependent people who are in treatment with methadone live longer
4. Long term treatment with methadone is better than short term treatment with methadone
5. A low methadone dose is not necessarily the best methadone dose
6. Methadone is the gold standard treatment for pregnant women who are opiate dependent
7. Methadone has drug overdose risks and benefits that you should understand
8. Methadone treatment requires a strong commitment to recovery
9. Methadone-assisted recovery is real recovery
10. Methadone is the single most effective treatment for opiate dependence
Methadone treatment is a lot of work.
But many people make the effort because the treatment works for them and they decide it’s worth the effort.
Commitment to overcoming stigma
The methadone patient must overcome the stigma that surrounds methadone treatment.
They have to get past family and friends who try to tell them that they are “trading one drug for another” or that they aren’t “really in recovery.”
They have to get past the voice in their own head that worries that maybe the naysayers are right.
They have to get themselves educated enough to know the facts, and recognize misinformation and myths about methadone that may prevent them from benefiting from the single most effective treatment for opiate dependence –methadone.
Commitment to treatment
Methadone is a treatment that helps people successfully manage opiate dependence as a chronic and relapsing condition.
Methadone prevents withdrawals, eliminates major cravings, and blocks the effects of other opiates. But only as long as the treatment continues. For many people, treatment may be most effective if continued for a period of years or decades.
This takes commitment.
Commitment to abstinence
Methadone clinics provide abstinence-based treatment.
Patients will not be permitted to stay in treatment if they do not demonstrate a commitment to abstinence.
Methadone provides strong but limited support for maintaining abstinence from opiate use.
It takes real effort to make the significant behavioral and psychological changes necessary to maintain abstinence from opiates during methadone treatment. And these are the changes that increase the likelihood of maintaining abstinence if at some point the patient chooses to discontinue methadone treatment.
Methadone is a powerful tool for recovery, but it is not a magic bullet or an easy “cure.”
Methadone is a treatment for opiate dependence. But people with opiate dependence often use other substances too, including cocaine and alcohol. Many continue use after they begin methadone treatment.
This is to be expected given the biological basis of addiction, the complexity of people’s lives, the fact that there are real reasons people use drugs, and the difficulty of changing psychological and behavioral patterns of long standing.
Using cocaine, alcohol or other drugs with methadone increases drug overdose risk. And use of other substances may make it more difficult for people to achieve the kind of stability in their lives necessary for sustainable recovery.
Methadone clinics monitor use of a range of substances, and methadone patients who do not demonstrate a commitment to abstinence face discharge.
Commitment to clinic-based treatment
Patients seeking methadone treatment for opiate dependence have to go to clinic-based programs.
This type of treatment is not available through private doctors in office-based settings (private doctors may only prescribe methadone for the treatment of pain in most cases).
New patients are required to go to the clinic to take their dose under observation every single day. Going to a clinic every single day (even on weekends) without a break, and for a long time takes real commitment.
Some days the visit is just to take the medication. Other days the patient must also provide a urine sample for a drug test. And other days the patient must participate in counseling.
“Clinic fatigue” is a real problem, and can become a barrier to treatment.
Patients can get a single take home dose for holidays or other days the clinic is closed. Beyond that, take-home doses have to be earned.
The medical director of the clinic is required by federal law to take into account certain criteria in deciding if a patient may be granted take-home doses.
Criteria include abstinence from use of drugs including alcohol, regular clinic attendance, lack of behavioral problems at the clinic, lack of known recent criminal activity, stable home environment and social relationships, length of time in treatment, and assurance of safe storage of the medication at home.
Once the patient is determined to be eligible for take-home doses, federal limits on the number of take-home doses are applied (state and clinic limits may also apply).
Under federal limits, patients are limited to a single take-home dose per week during the first 90 days of treatment. This increases to two per week during the second 90 days in treatment, and three per week during the third 90 days in treatment.
In the remaining months of the first year of treatment, patients may be given up to a 6-day supply of take-home medication.
After one year of continuous treatment, a patient may be given up to a two-week supply of take-home medication. And after two years of continuous treatment, a patient may be given up to a one-month supply of take-home medication (but must make monthly visits to the clinic).
Commitment to recovery
People who are participating in methadone treatment have made a strong commitment to recovery. They are making a real effort every day to live with and seek to overcome their opiate dependence –just like everybody else who is in recovery.
Please support people in methadone treatment in their right to choose their own path to recovery.
Think about how insulting and demoralizing it would be to have your efforts and successes disparaged by family, friends, or people who have chosen other paths to recovery.
Methadone-assisted recovery is real recovery!
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Thanks, Tom, another educational post!
Great job! Only one thing I would change, perhaps–the statement “Methadone clinics provide abstinence based treatment”. The term “abstinence based treatment” almost always is used in conjunction with traditional rehabs/12 step based groups that do not use medication–especially long term. Methadone clinics provide “Medication assisted treatment” or MAT.
One other thing to add–not all clinics discharge patients for testing positive–even repeatedly–for substance use. In fact, Best Practices standards do not support doing this. MMT started out as a Harm Reduction practice, and for some patients it remains so, while for others, it is recovery.
For example: Patient X has an addiction to IV heroin and to intranasal cocaine. They sign up at the clinic, start on methadone, and after reaching a stable dose, are able to cease using heroin completely. They also decrease–but do not completely eliminate–their cocaine usage. However, they are no longer injecting drugs, no longer mixing two drugs, and are much more functional in their day to day life. They also have the advantage of seeing medical personnel daily, getting counseling and referrals, and seeing patients who are free of illicit drugs and doing well.
Were the clinic to discharge the patient for testing positive for cocaine, the patient would almost certainly resume illicit heroin abuse as they would be suffering withdrawals from the methadone (administrative withdrawals are notoriously brief), and would be exposed to all the dangers they were exposed to before treatment, plus the added danger of a lowered tolerance, possibly leading to an overdose.
One thing that bothers me greatly is seeing methadone being used by some clinics as a reward or punishment–i.e., if you behave, like a good little junkie, and stop using that cocaine/alcohol/benzos/speed, you will get your reward (methadone). But, if you are naughty and USE those drugs, we will punish you by witholding your reward until you comply. The problem with this is that methadone only treats opioid addiction and is not effective against other forms of drug abuse, yet the patient–who needs methadone in order to cease their opiate abuse–is expected to stop using the other drugs cold turkey and with no assistance. If the patient wishes to receive treatment for their other addictions, they almost always find that no rehab will accept them and agree to continue their MMT while they are there. There are, literally, fewer than ten such places in the country–maybe not even that many. I know of only two myself. SO, they are stuck between a rock and a hard place, threatened with losing treatment for one addiction if they display symptoms of another, untreated addiction.
Zenith, great comments!
On the issue of how to describe methadone maintenance treatment (MMT)…
I think medication-assisted treatment is an accurate way to describe MMT, and I use that term often.
I also think it is accurate and important to say that MMT is an abstinence-based treatment for opiate dependence. The goal is to support the patient in maintaining abstinence from the illicit/problematic use of opiates (this is the program goal and the goal of the vast majority of patients). I am not familiar with any MMT programs that consider ongoing use of heroin or other illicit opiates to be acceptable.
I realize I’m engaged in “taking back” the term abstinence-based treatment from some who would prefer a narrower use of the term. But I think it’s important that MMT patients lay joint claim to that terminology.
As you know, there are those who try to claim that people in MMT aren’t in recovery. I think it is important to be clear that MMT patients are in recovery and are abstinent.
I consider MMT to be both a harm reduction strategy and recovery.
I strongly agree that medication should not be used as a reward/punishment…and yes it happens a lot.
I agree that clinics should not simply discharge people for use of opiates or other substances.
Use of opiates indicates that the treatment is not adequately effective, and the treatment needs to be modified. This might mean adjusting the methadone dose or counseling approach. It might mean that the patient needs help with practical issues like safe housing.
Use of other substances to the point that the use meets diagnostic criteria indicates that abuse/dependence related to other substances is an issue that should be addressed.
Use of cocaine, alcohol, benzos or speed in combination with methadone is an overdose risk. I am not familiar with any MMT program that would be satisfied with ongoing use of these other substances as a status quo.
This does not mean that immediate discharge is the right response (it’s not). And using methadone as a reward/punishment for use/non-use of other substances is definitely not okay.
Good MMT programs would not discharge a patient for testing positive for these substances…even repeatedly. But ignoring the issue isn’t the right response either. That would place both the patient and the program at risk.
Although I agree with your comments, I guess I continue to think that describing MMT as an abstinence-based treatment is accurate and important.
Interesting idea about “taking back” the term. I agree of course that MMT IS recovery, for most of those who use it. I just have a long standing negative association with the phrase “abstinence based recovery” since it means something to most people that is in conflict with MMT (i.e., no use of mood altering drugs, period).
I also disagree with the common recovery concept that if you are addicted to one substance you are naturally and automatically addicted to them all. For example–let’s say we have a patient who has been abusing IV heroin for decades and whose health and life have suffered mightily for it. Let’s say they also occasionally smoke a joint, which, though technically illegal, is not causing problems in their life. They seek treatment for heroin addiction at a methadone clinic, cease using heroin, and are doing very well. Yet, because they smoke pot a couple of times a month, the clinic threatens discharge. But they did not come to the clinic seeking help for a pot problem–in fact, they don’t have a pot “problem”. There are many ways to look at such an issue and I only recently started going “out of the box” on this and asking myself to really think WHY is such treatment necessary, what does it accomplish, why is it done.
Now–obviously it is harmful to combine certain drugs. However, the patient who needs help with addictions to substances other than opioids often finds themselves in a true pickle, because very few places will accept current MMT patients for treatment of other addictions unless they want off methadone too–so, where are they to go for help? If they go to 12 step groups–which are after all, supoort groups, not “treatment”–they are likely told that they must get off methadone there as well. I once spent an entire day on the phone with dozens of inpatient rehabs trying to find one that would accept someone on MMT and continue their medication while treating them for crack addiction. In the end the patient had to fly from Texas to WV for treatment–he was able to do so because he had a wealthy family ready to assist him, but most pts do not have this luxury.
What would you suggest for those pts with poly drug addictions who want treatment but also want to remain on MMT?
I’ve had experience running a program for people with opiate dependence for a large mental health and drug treatment agency, and I’ve interacted with many other treatment providers on behalf of clients.
I’ve learned that it is important for the sake of MAT patients to help other providers see how MAT fits into a broader recovery plan.
I understand the negative association some have with the term “abstinence based treatment.” Just like I understand the negative association some have with the term harm reduction.
What is important to me, is helping clients and their families learn about how harm reduction, MAT, outpatient counseling, residential treatment and other recovery approaches offer different tools that can and should work together in support of recovery.
Educating providers is often necessary too, because most providers focus only on the modality they offer and don’t work very hard to integrate/coordinate services in the best way for clients. Part of this is using common language.
Language is extremely important. I firmly believe that word choice in the field of addiction makes a profound difference in outcomes for clients –especially in the context of medical care, corrections and drug treatment.
I agree with you Zenith about the false assumption that an opiate dependent person is automatically addicted to all substances. I know many people in recovery for opiate dependence who use THC, for example, with no negative effect on their recovery from opiate dependence. There is no one size fits all rule on this.
I don’t think residential treatment is always required to address use of other substances. And where I live we do have several short term residential treatment programs that will accept people in MMT or MAT with Suboxone, and one long term treatment program that will accept people in MAT with Suboxone.
It’s exactly the ignorance of programs who reject people on MAT, including some 12 step programs, that makes me feel so strongly about the need to counter those who would like to marginalize MAT or MAT patients.
I chose my words when I said, “Methadone clinics provide abstinence-based treatment.” And I dedicated a section of the post to methadone as an abstinence-based treatment specifically because I think that defining the term abstinence in terms of illicit/problematic use of substances is accurate and important.
Zenith, I really appreciate and enjoy your comments. You obviously have a lot of knowledge and experience. You have great insights, your examples ring true and you are very on point. Thank you for reading and commenting!
I have been waiting patiently for the next installments (hint! hint! lol!) and look forward to the suboxone series as well.
I agree with the statement that MAT should be a “part” of recovery and that the others need to work in conjuction with MAT. I have always felt that MAT alone was just treating the physical side of the addiction. Counseling and 12 step type program needed to be utilized in conjunction with MAT to work on the mental aspect of addiction. One without the other is not adequate.
MAT w/o a recovery program means that even if you successfully detox off the methadone, the real reason behind your addiction is still there and your chances of staying clean are basically zero.
The same with the recovery program alone. I failed traditional treatment 4 times and I was starting to think I was hopeless! Within just a few months of getting out, every single time I would fail. Looking back now, I wish I had known about MAT then! I think I would have had a better chance of recovery if I had been on MAT along with the “traditional” recovery program.
I have been on MMT for 10 years now and while I never intended to stay on it this long, (I was an opiate addict for over 16 years) and I have family members who don’t understand why I am still on MMT and think I should get off. BUT I am not too niave to believe that I can get off MMT to please anyone else. It has to be when I am ready and again, I never intended to stay on it this long, but I remember what it was like to be an addict and if it means one or the other, then I will stay on MMT the rest of my life.
I also want to comment on what Zenith said about the clinic using your dose as a reward/punishment. You don’t know HOW MANY TIMES this has happened at the clinic I use to attend. It was so frustrating! Why didn’t they see continuted opiate use as a “problem with the treatment” rather than the pt misbehaving? I mean come on, that is the whole reason behind opiate addiction being treated with ORT anyhow, because we now know it is not a behavior problem but a real physical problem. So that says to me if someone is still abusing opiates, or starts testing pos for opiates after years of stable treatment, then something is wrong and their treatment needs to be adjusted.
My “couselings” sessions there were a joke! I was required to see the counselor once every 3 mths and all that consisted of was siging a treatment plan that they already had typed up by copying my last treatment plan. There is no real counseling that goes on there. (I get my counseling from an addiction support group and a 12 step program that I found on my own, but again, I would NEVER tell them I am on MMT because they think I should be free of ALL substances.)
This was also the same clinic that has a silent dose cap at 120mg. Long story short, I had been on MMT for 8 years at the same clinic and 120mg for over 5 years. I was a pt who never caused any problems, had not had a bad UA in over 6 years and even paid my clinic fees a year in advance with my income tax refund.
I was having actual w/drawals symptoms which the nurse documented in my chart and severe cravings. When I asked the doc to increase my meds, he refused and told me I had to have a peak and trough. I ahd no problem with that because I KNEW I was having problems and the test would prove it. My results were T 213 and P 508 which according to the info I had on P&T showed at the very least there was problem with a drastic difference in my P&T amounts. That he should have at least considered split dosing but he said I was OVER medicated and reduced my dose! I tried to show him the info I had gotten about P & T results, but he refused to even look at what I had. He misinterpreted my peak and trough to suit himself, reduced my dose and told me if I couldn’t be maintainted on 120mg then maybe it was time for me to get off methadone treatment.
Needless to say, I left that clinic. But that is the kind of things MMT clients face with clinics these days especially the for profit clinics. It sounds horrible of me to say this, but I felt like they were just a legal drug dealer. They could go up on their prices, they could withhold what I needed just because I didn’t do exactly what they wanted, they could increase my dose or decrease my dose based on what THEY wanted and not on what I NEEDED and what was I going to do? NOTHING! Because at 120mg a day, I am dependent on methadone and wouldn’t dare do anything to give them cause to kick me out or rapidly detox me.
On the same token, I am thankful for MMT. It gave me my life back when I thought I was hopeless and would never get better.
It is just sad that there can’t be some kind of “happy medium” where the clinics give the pts the respect they deserve and some control over their own treatment plan.
Have you heard of this scenario–my son has been advised NOT to go off Subox by 2 shrinks and a treatment center.
He is a hard core poly substance abuser, but primarily IV heroin, for 10 years. He has never but together any significant clean time. He got state insurance a few months ago, so he started seeing a psychiatrist. He also went to a 28 day treatment center after a brief relapse. Along the way he saw another doctor. All advise him to stay on Subox, 8mg/day, but he has got it in head to get off. I have some influence in that he values my opinion. I’m thinking I should encourage him to stay on it? Obviously, these professionals know he is very high risk.
As far as stigma…I don’t think people should even tell anyone. The all or nothing recovery is a huge myth, I myself was very biased against methodone/Subox. I know now it some addicts only hope.
Lou –I’d like to hear what is making your son want to discontinue the medication. If the Suboxone is working, it would be important to know why he wants to stop treatment. There are barriers to people staying in treatment even when it’s working, and those need to be addressed to protect the person’s recovery.
If it’s not working (he is still using) I’d look at an increase in dose before deciding it’s not a good treatment fit…8mg is a moderate dose…16mg is a common dose so he has some room to increase his dose if needed.
Tell me more!
Ruthann thanks for the great comment.
Do you belong to junkjunk.ning.com? I’d love to have your perspective and experience heard there. We have a Monday night chat you might enjoy too in the chat room.
I’ll try to get busy on number 9 and 10!
Thanks again and keep commenting!