How to Avoid the Methadone Trap

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A patient in my office for addiction treatment
once statedWhen 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., lt30 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 3040 mg per day dose is gradually
raised to a maintenance level of 60120 mg per
day. Indeed, multiple randomized trials have
found that patients have better outcomes,
including retention in treatment, with higher
doses (80100 mg per day) than lower doses.
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• 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 48 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?

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2) Buprenorphine is recommended to be started
when a patient is at 30-60 MME of an opiate. So,
doesnt 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 dont Methadone clinics report to the
prescription monitoring data base? Doesnt 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 patients
health and the clinics profits.
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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.The
Buprenoprhine 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 answerIt 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
pillsTM. 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 PillsTM.
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