It’s Friday!
1 day ago
Tuesday, March 24, 2009
Being a recovering opiate addict that is on a Methadone Maintenance program, I have personally encountered a TON of stigma and discrimination, so it is very nice to finally see some positive stuff out there. I came across a couple of letters for families and loved ones and one for physicians. They are both very well written, very informational, and they cut right to the point. They don't make excuses or anything like that. They just get to the freakin' point. The following is the first letter to families and loved ones to help educate them and reduce stigma and myths about MMT. I copied this letter from the following link: http://www.readybb.com/watchdog/viewtopic.php?t=7301
I decided it might be helpful to make this a sticky in case anyone needs it or wants to use it to help educate their family members about MMT--several folks have told me it was helpful to them, so here it is again:
Dear Family member or Friend;
This letter will attempt to address some common concerns of those of you who have loved ones on MMT (methadone maintenance treatment). There are many misconceptions and common misunderstandings surrounding this treatment, which education and knowledge about the treatment may alleviate. Methadone, unfortunately, is surrounded by unfair stigma and prejudice based on fears and assumptions, not science and medicine. Family members quite naturally are concerned about their loved one's health and future and want the best for them, and they may have heard some things about MMT that cause them alarm.
One of the most commonly voiced concerns is that MMT is "just trading one addiction for another". Many feel that the only way to truly recover from addiction is to abstain from all mood altering substances. At one time this was thought by most to be true. However, science has discovered that with long term opiate addiction (opiates meaning heroin, vicodin, morphine, oxycontin, etc), the brain's natural production of endorphins is shut down. Endorphins are the chemicals we all have that enable us to feel pleasure and happiness. We all have opiate receptors in our brains for these chemicals to attach to. The word "endorphin" comes from "endogenous", meaning coming from within, and "morphine"--i.e., morphine from within. These chemicals are released when we eat delicious food, make love, enjoy a beautiful sunset, exercise (runner's high), or even when we are injured, as natural painkillers. Without this natural chemical, life can be very difficult and painful.
When we flood our systems with exogenous (outside) opiates, our bodies recognize that we have plenty on board and cease to manufacture our own natural endorphins. This results in the patient feeling extremely ill when withdrawing from opiates. They experience depression, irritability, exhaustion, anger, sleeplessness, hopelessness, etc. This happens to all opiate abusers when they cease taking opiates and is to be expected. Some patients, especially those with short term addiction histories, will be able, after a few weeks or months of abstinence, to get their natural endorphins back into good working order again, and will begin to gradually improve. However, for many, the damage done is permanent. This has been demonstrated in many scientific studies involving CT scans of the addicted brain. For these patients, no amount of abstinence, group therapy, meetings, will power, or good intentions will undo the fact that their brains simply will no longer produce endorphins in sufficient quantity to enable them to live a normal, happy life. This is, in fact, very similar to the way in which diabetics require supplemental insulin because their pancreas no longer manufactures insulin. In addition, there are some patients who have never had a normally functioning endorphin system, who have struggled since birth with crippling depression, and who became addicts in an effort to relieve their constant emotional and mental misery. For them, too, abstinent recovery works poorly or not at all. This is where MMT comes in.
Methadone is a synthetic (man made) opioid drug, used to treat pain and addiction. It has some unusual properties that make it well suited to addiction treatment. It is a long acting drug, remaining active in the tissues for up to 72 hours after ingestion. It does not cause the high or euphoria caused by other, short acting opiates because it is taken up gradually by the brain, not suddenly and sharply. In fact, many overdoses involving this drug are due to people seeking the high they have come to expect with other opiates and not getting it, so they take more and more. A stable methadone patient who is not mixing the medication with other drugs--particularly benzodiazepines, which can sometimes be a very dangerous mixture-- and who is on a medically appropriate dose will not be "high" or sedated. These patients are able to work, operate a vehicle, care for children, and do anything else a normal person can do. Their minds are not "clouded". Some of these rumors may come from observing patients who are abusing other drugs, or are taking more than prescribed.
Methadone, properly administered and taken, balances the chemicals in the brain so that the patient feels normal. Unfortunately, standard antidepressants generally do not work well for those with dysfunctional endorphin systems because they target serotonin, not endorphins.
Methadone is also unique in that it does not attach to all the opiate receptors in the brain, leaving some open to encourage production of natural endorphins if possible. This may contribute to the healing of the addicted brain. Methadone is commonly referred to as "replacement" or "substitution" therapy, and most think that this means it is replacing the heroin, etc that the patient was abusing, when in fact, it is replacing the natural endorphins no longer being manufactured by the patient's brain, in the same way synthetic insulin substitutes for that not being made by the diabetic's own organs. Methadone treatment enables the patient to return to a normal, productive, law abiding life in a great many cases, and even when the patient continues abusing other drugs, etc, it may lower their chances of contracting a disease by reducing their drug use, and enables them to see a medical professional for assistance and referrals on a daily basis.
However, for many (not all) MMT patients, long term therapy--even life long--may be needed to maintain recovery. Addiction is a chronic, incurable disease. We do not tell diabetics, blood pressure patients, and epileptics to discontinue their medications because we know that if they do, the active disease will return. Why, then, do we encourage recovering, thriving MMT patients to do so, when the relapse rates for those discontinuing MMT is greater than 90%? Methadone is the most effective modality of treatment for opiate addiction available today--far more effective than traditional rehabs and 12 step groups alone. By no means is it the treatment of choice for every opiate addict--however, if abstinent methods have failed many times over, there is little point in continuing to try the same thing expecting different results "this time".
Most experts recommend that a patient remain in MMT a MINIMUM of 3 years after they cease illicit drug use. At that time, if, and only if, the PATIENT themselves wishes to begin a taper program, one can be attempted. Tapering must be done on a slow and gradual basis--no more than 10% of the dose every 2 weeks to a month. If the person begins experiencing severe cravings or withdrawals, they should stop and return to an adequate dose until symptoms subside. If the person relapses, this should not be seen as failure or weakness, but only as evidence that they may require ongoing therapy to control their symptoms. Family support is ESSENTIAL to the patient's successful recovery on MMT, and continued questions of "When are you going to get off that stuff? It's just a crutch!", etc undermine treatment efforts and sabotage recovery, leaving the patient confused, sad and frustrated instead of feeling proud and happy at the improvements in their lives. Addiction is a deadly disease and there are few effective treatments for it, so please support your loved one's recovery efforts and praise them when you see improvements. There is nothing positive to be gained by forcing them off treatment before they are ready.
If you would like more information about MMT, please seek out reputable sources such as WWW.SAMHSA.Gov, the American Assoc. for the Treatment of Opioid Disorders (AATOD) website, the White House Office of Drug Policy, etc.
_______________
_________________
Zenith
Director, ARM-Texas Chapter
C.M.A. (Certified Methadone Advocate)
"Question Authority!"
Dear Family member or Friend;
This letter will attempt to address some common concerns of those of you who have loved ones on MMT (methadone maintenance treatment). There are many misconceptions and common misunderstandings surrounding this treatment, which education and knowledge about the treatment may alleviate. Methadone, unfortunately, is surrounded by unfair stigma and prejudice based on fears and assumptions, not science and medicine. Family members quite naturally are concerned about their loved one's health and future and want the best for them, and they may have heard some things about MMT that cause them alarm.
One of the most commonly voiced concerns is that MMT is "just trading one addiction for another". Many feel that the only way to truly recover from addiction is to abstain from all mood altering substances. At one time this was thought by most to be true. However, science has discovered that with long term opiate addiction (opiates meaning heroin, vicodin, morphine, oxycontin, etc), the brain's natural production of endorphins is shut down. Endorphins are the chemicals we all have that enable us to feel pleasure and happiness. We all have opiate receptors in our brains for these chemicals to attach to. The word "endorphin" comes from "endogenous", meaning coming from within, and "morphine"--i.e., morphine from within. These chemicals are released when we eat delicious food, make love, enjoy a beautiful sunset, exercise (runner's high), or even when we are injured, as natural painkillers. Without this natural chemical, life can be very difficult and painful.
When we flood our systems with exogenous (outside) opiates, our bodies recognize that we have plenty on board and cease to manufacture our own natural endorphins. This results in the patient feeling extremely ill when withdrawing from opiates. They experience depression, irritability, exhaustion, anger, sleeplessness, hopelessness, etc. This happens to all opiate abusers when they cease taking opiates and is to be expected. Some patients, especially those with short term addiction histories, will be able, after a few weeks or months of abstinence, to get their natural endorphins back into good working order again, and will begin to gradually improve. However, for many, the damage done is permanent. This has been demonstrated in many scientific studies involving CT scans of the addicted brain. For these patients, no amount of abstinence, group therapy, meetings, will power, or good intentions will undo the fact that their brains simply will no longer produce endorphins in sufficient quantity to enable them to live a normal, happy life. This is, in fact, very similar to the way in which diabetics require supplemental insulin because their pancreas no longer manufactures insulin. In addition, there are some patients who have never had a normally functioning endorphin system, who have struggled since birth with crippling depression, and who became addicts in an effort to relieve their constant emotional and mental misery. For them, too, abstinent recovery works poorly or not at all. This is where MMT comes in.
Methadone is a synthetic (man made) opioid drug, used to treat pain and addiction. It has some unusual properties that make it well suited to addiction treatment. It is a long acting drug, remaining active in the tissues for up to 72 hours after ingestion. It does not cause the high or euphoria caused by other, short acting opiates because it is taken up gradually by the brain, not suddenly and sharply. In fact, many overdoses involving this drug are due to people seeking the high they have come to expect with other opiates and not getting it, so they take more and more. A stable methadone patient who is not mixing the medication with other drugs--particularly benzodiazepines, which can sometimes be a very dangerous mixture-- and who is on a medically appropriate dose will not be "high" or sedated. These patients are able to work, operate a vehicle, care for children, and do anything else a normal person can do. Their minds are not "clouded". Some of these rumors may come from observing patients who are abusing other drugs, or are taking more than prescribed.
Methadone, properly administered and taken, balances the chemicals in the brain so that the patient feels normal. Unfortunately, standard antidepressants generally do not work well for those with dysfunctional endorphin systems because they target serotonin, not endorphins.
Methadone is also unique in that it does not attach to all the opiate receptors in the brain, leaving some open to encourage production of natural endorphins if possible. This may contribute to the healing of the addicted brain. Methadone is commonly referred to as "replacement" or "substitution" therapy, and most think that this means it is replacing the heroin, etc that the patient was abusing, when in fact, it is replacing the natural endorphins no longer being manufactured by the patient's brain, in the same way synthetic insulin substitutes for that not being made by the diabetic's own organs. Methadone treatment enables the patient to return to a normal, productive, law abiding life in a great many cases, and even when the patient continues abusing other drugs, etc, it may lower their chances of contracting a disease by reducing their drug use, and enables them to see a medical professional for assistance and referrals on a daily basis.
However, for many (not all) MMT patients, long term therapy--even life long--may be needed to maintain recovery. Addiction is a chronic, incurable disease. We do not tell diabetics, blood pressure patients, and epileptics to discontinue their medications because we know that if they do, the active disease will return. Why, then, do we encourage recovering, thriving MMT patients to do so, when the relapse rates for those discontinuing MMT is greater than 90%? Methadone is the most effective modality of treatment for opiate addiction available today--far more effective than traditional rehabs and 12 step groups alone. By no means is it the treatment of choice for every opiate addict--however, if abstinent methods have failed many times over, there is little point in continuing to try the same thing expecting different results "this time".
Most experts recommend that a patient remain in MMT a MINIMUM of 3 years after they cease illicit drug use. At that time, if, and only if, the PATIENT themselves wishes to begin a taper program, one can be attempted. Tapering must be done on a slow and gradual basis--no more than 10% of the dose every 2 weeks to a month. If the person begins experiencing severe cravings or withdrawals, they should stop and return to an adequate dose until symptoms subside. If the person relapses, this should not be seen as failure or weakness, but only as evidence that they may require ongoing therapy to control their symptoms. Family support is ESSENTIAL to the patient's successful recovery on MMT, and continued questions of "When are you going to get off that stuff? It's just a crutch!", etc undermine treatment efforts and sabotage recovery, leaving the patient confused, sad and frustrated instead of feeling proud and happy at the improvements in their lives. Addiction is a deadly disease and there are few effective treatments for it, so please support your loved one's recovery efforts and praise them when you see improvements. There is nothing positive to be gained by forcing them off treatment before they are ready.
If you would like more information about MMT, please seek out reputable sources such as WWW.SAMHSA.Gov, the American Assoc. for the Treatment of Opioid Disorders (AATOD) website, the White House Office of Drug Policy, etc.
_______________
_________________
Zenith
Director, ARM-Texas Chapter
C.M.A. (Certified Methadone Advocate)
"Question Authority!"
This next letter is the one for physicians copied from the following link: http://www.capqualitycare.com/dear_doctor.htm
Opioid Treatment Program Name ADDRESS · CITY, STATE · ZIP · TEL NO. · FAX: NO. · EMAIL (Revised 11/18/05)
Date: RE: (Patient's Name)
Dear Doctor:
This is a general letter in reference to our mutual patient(s) maintained on methadone in our Opioid Agonist Treatment Program (OTP).
Methadone maintenance has been used in the treatment of opioid dependence since the 1960's. The stabilized methadone-maintained patient usually develops complete tolerance to the analgesic, sedative and euphoric effects of methadone. The patient also avoids the opioid abstinence (withdrawal) syndrome and craving for opiates. Sedation in the stabilized methadone maintained patient is almost always attributable, concurrent medical conditions or to methadone’s interaction with other drugs, and far less frequently to the non-compliance with treatment goals and abuse of methadone.
The best policy is to coordinate your medical treatment of the patient with his/her Outpatient Treatment Program (OTP). Confidentiality regulations that apply to substance abuse treatment are unique and restrictive; a signed release of information is required before our staff can acknowledge a person is a patient and discuss specific issues about his/her treatment. However, even without a release of information, our medical personnel can direct you to appropriate resources or answer questions regarding major drug-drug interactions, cardiac considerations, safety of breastfeeding, methadone and pregnancy issues, et cetera.
Pain management in the methadone maintained patient is frequently misunderstood. The stabilized patient may experience some analgesia for 2-6 hours from their daily maintenance dose but there is substantial individual variation, and the analgesia is often inadequate even during that brief interval. Substantial pain relief will most often require prescription of additional medication appropriate for the nature of the pain, including long and short acting opioids. Methadone can be an excellent analgesic but to be effective for pain management it must be administered in divided doses, 2 to 4 times a day, and in a total daily dose that exceeds the patient’s usual maintenance dose for the avoidance of craving and opiate withdrawal symptoms.
For the medical provider treating a methadone maintained patient for pain, coordinating and documenting treatment with the OTP is best from both medical and legal perspectives. It is essential to obtain a release of information from the patient and contact his or her clinic in order to establish coordination of treatment with the Medical Director or his designee. While some methadone maintenance patients can be managed similarly to patients without an addiction history, others must be monitored closely. Personnel at the clinic can provide information on methadone’s significant reactions with other medications, induction protocols, maintenance dosing, and metabolic differences from other opiates. This information is available on the internet at the links indicated, below.
We suggest that you ask for a letter from the methadone maintenance clinic or make a note of our verbal interactions, in addition to using a standard pain contract and documenting the source of pain and the history of its treatment. When considering analgesia, as already noted, some methadone-maintained patients can be managed the same as those without an addiction history. Others must be monitored closely when utilizing medications associated with neurobiological reward mechanisms either as a stand alone euphoric affect or use in combination with methadone. There will always be some individuals that will abuse any number of substances, such as stimulants, or benzodiazepines with methadone maintenance therapy. Judgment about a specific patient can be made, more accurately when information is obtained from the OTP personnel.
If opioid medication is required for pain, it is widely recognized that the required dose will be at least 10% to 50% greater than that required for non-opioid tolerant individuals. This is due not only to high opioid tolerance encountered in our population, but also to the reduced pain thresholds of methadone-maintained patients. Also, administration of opioid analgesics may need to be more frequent than usual (q 3-4 Hr versus q 4-6 Hr for non opioid tolerant individuals).
If it is necessary to prescribe opioids for self-administration, long-acting drugs are preferred for chronic pain treatment, including methadone. When short-acting opioids are indicated, a week's supply or less of medication with a small number of prescription refills, if any, serve the needs of most methadone maintained patients. Talwin, Stadol, Nubain, and buprenorphine can precipitate severe opioid withdrawal (abstinence syndrome). Many patients experience discomfort with Ultram (tramadol). Also be aware of the abuse potential of this medication and seizures associated with high doses of tramadol. Darvon (propoxyphene) and Demerol (meperidine), cause seizures in methadone maintained patients. Naltrexone, and naloxone precipitate severe withdrawal.
Some anticonvulsants, tricyclic antidepressants, SSRIs, etc., can be used adjunctively for the treatment of pain. However, NSAIDs, might promote cirrhosis in patients with Hepatitis C, and should be used with caution when HCV is known to be present. Dilantin, phenobarbital, Tegretol and rifampin should be avoided because they strongly induce CYP 3A4 metabolism of methadone. If necessary, use of these drugs without causing undue suffering can be accomplished if the methadone dose is increased, even doubled, to balance the rapidly increased metabolism. Caution must then be used when such agents are discontinued to avoid overdose or intoxication when such metabolism rapidly diminishes. Valproic acid, divalproex, and gabapentin are useful alternatives for anticonvulsants. For tuberculosis treatment, ethambutol may substitute for rifampin, when not contraindicated by hepatitis.
Methadone maintenance treatment is NOT a contraindication for the appropriate use of psychotropic medication in the 60% or more of patients with addictive disorders having Axis I psychiatric comorbidity. While most psychotropic medications have interactions with methadone, some of which can be consequential, and others have the potential for abuse, most can be used with proper monitoring and awareness. Making individual determinations in each patient regarding the use of benzodiazepines or stimulants is preferable to precluding their use entirely in methadone-maintained patients. OTP clinical staff can help you assess risks of diversion, drug abuse, or medication interactions.
Regarding patients whose stabilization of significant psychiatric pathology or chronic pain is attributable or has occurred in the course of methadone maintenance, discontinuation of methadone is relatively contraindicated. Substantial evidence exists that methadone itself may engender potent psychotropic benefits as an antidepressant, antipsychotic, and stabilizer of labile affective states.
Finally, there are few contraindications for stabilized methadone-maintained patients regarding treatment of hepatic disease, HIV-related illness, or organ transplantation.
Useful information about methadone’s significant interactions with other medications and its metabolic differences from other opiates (such as its metabolism by CYP450 2D6 enzymes, propensity for accumulation, slow onset of action, etc) is readily available on the Internet or upon request from our clinic. Please see the following resources from the www.atforum.com web site concerning methadone-drug interactions, cardiac considerations, and dosing and safety issues:
http://www.atforum.com/SiteRoot/pages/addiction_resources/Drug_Interactions.pdf, http://www.atforum.com/cardiacmmt.shtml and http://www.atforum.com/dosingandsafety.shtml
Additional information on methadone metabolism and dose ranges required for effective treatment appear on the “Articles” or “Links” pages at www.capqualitycare.com. If discussion of clinical issues or transfer of records regarding our mutual patient is required, please have the appropriate release of information forms signed and contact us.
Sincerely,
(Medical Director)
1 Comment:
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- Finding Myself said...
April 3, 2009 at 10:12 AMWow VERY Interesting and I would love to copy this to my blog! Great reading too by the way
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