Doctors, what's the deal with methadone?

[Kalhoun]

The subject of methadone came up in the House thread, and there was some discussion about the dangers of methadone. I googled around and found this:

http://www.helium.com/items/279214-dangers-of-prescription-methadone

To me, it seems like the only difference between Methadone and heroin is the legality of it. It also seems that the only benefit (not that it's minor) is that you lessen the chance of ODing or picking up sickness or disease. The withdrawal is as difficult, if not worse, and the chance of ODing due to a mixture of drugs is very real.

So to my question...if it's just as dangerous as heroin, why is it legal and why don't they just use controlled dosage of heroin to maintain junkies?

[outlierrn]

http://en.wikipedia.org/wiki/Methadone#Effect

Not saying it's perfect, but it blocks the high as well as the withdrawal

[Qadgop the Mercotan]

Methadone is a very long-acting opiate, useful for chronic pain relief.

It also has less of a 'high' than heroin, morphine, oxycodone, and other popular drugs of abuse, in part because of its long-acting nature. The euphoria of methadone is far less than that of the other opiates mentioned above by me. In fact, one hallmark of the methadone addict is that they're often coherent enough to actually engage in goal-directed activity, like cleaning, shopping, or even working, while on the drug.

As a result, one may get an opiate addict to be a semi-productive citizen while maintained on methadone. I actually know of a surgeon who practices (with the blessing of the Medical Board) while on methadone maintenance (I'd never go to him).

Also, methadone has some utility in discouraging use of those other opiates, if a person is already on high-dose methadone, as the euphoria of heroin, etc. will be severely blunted.

It's also useful in detoxing someone from opiates slowly, with reduced side-effects.

Even so, methadone is abusable, easy to overdose and die with, and takes a special license to prescribe if you're using it to treat opiate addiction.

As for controlled heroin doses, well, an active addict tends to escalate the dose to try to recapture the euphoria that he recalls so well from earlier using experiences. That's how heroin addicts end up on massive doses of the stuff (or dead, or both). And that's why few heroin addicts stick with scheduled, fixed doses of the stuff.

I'm not a fan of methadone maintenance; it generally requires very high doses to adequately block the effects of heroin or other opiates, and methadone is a bitch and a half to detox off of at those levels, far worse than heroin, frankly. That's mainly because it takes weeks to months to detox from methadone, rather than the 3 or so days it takes for heroin. And the withdrawal symptoms are pretty much the same.

But methadone is very useful for treating some nasty malignant pain syndromes.

[Kalhoun]

Thanks, QtheM. Interesting and helpful, as per usual.

[Tom Tildrum]

How is methadone typically taken? I.e., by mouth, by injection? (Suppository?)

[Moirai]

I think you can drink it, like a little glass of juice.

[cantara]

My wife is on methadone for chronic pain associated with Multiple Sclerosis. She has neuropathic pain in her face, arm and leg all on the left side. She also has chronic headaches. She has been going to a recommended pain clinic and the Dr. had prescribed this treatment.

She is currently on 20mg/day orally. She gets it in 5mg/ml solution with water. It is usually mixed with Tang. She dislikes the taste of the meds and dilutes it in iced tea and the Tang doesn't mix well.

We'd asked for pills for a vacation that we had taken and discovered that my insurance company won't cover them, only the solution. The cost difference was negligible, I believe. We paid out of pocket for the convenience. As far as meds go, they are very cheap (under $50/month). Far less than the Rebif (http://en.wikipedia.org/wiki/Rebif) at $1500/month.

It is also a pain to get from the pharmacy. Only approved pharmacists/pharmacies can distribute the meds, and only for doctors that they have on record. This means a special trip for us once a month to the only place that we can get them from. It is also a pain to try to manage the timing of it. Her meds were going to be finished on a Sunday, and we called the previous Monday (since it we were going to be in the area). They wouldn't fill it because we were more than 2 days early.

She had found that Tegretol (http://en.wikipedia.org/wiki/Tegretol)had worked wonders for her and she would rather be on that...if it weren't for her allergic reaction to it.

[Qadgop the Mercotan]

cantara, that sounds odd that they so restrict the dispensing for your wife. It sounds more like a methadone maintenance clinic than a pain clinic in that regard. Are you in the US?

Perhaps some states restrict methadone prescribing more at present, but in most US states, any doctor can prescribe methadone for pain if they have a valid DEA number, and any pharmacy that carries it should fill such a prescription. The additional restrictions come in if one is prescribing it for maintenance of an addiction.

Has your wife tried gabapentin for neuralgia?

[obfusciatrist]

I actually know of a surgeon who practices (with the blessing of the Medical Board) while on methadone maintenance (I'd never go to him).


Off topic but out of curiosity, is that information about the surgeon available to patients in any way other than the surgeon divulging it himself?

[Really Not All That Bright]

Off topic but out of curiosity, is that information about the surgeon available to patients in any way other than the surgeon divulging it himself?
The state medical board will maintain a publicly available discipline history for him, but otherwise probably not, assuming he hasn't committed a crime or ethics violation due to the methadone/while on methadone or other opiate.

[gigi]

Perhaps some states restrict methadone prescribing more at present, but in most US states, any doctor can prescribe methadone for pain if they have a valid DEA number, and any pharmacy that carries it should fill such a prescription. The additional restrictions come in if one is prescribing it for maintenance of an addiction.Yeah, one of my clients had to go every day to pick hers up.

[Broomstick]

Methadone is a tool, not a miracle cure.

I used to work at a methadone clinic. It really did help some people. In other cases, yes, it was harmful. Part of the problem is that too many in the legal system use it as a cure-all for all types of drug addiction (there was one judge who kept trying to get coke addicts onto methadone maintenance for awhile... don't get me started...) This is why you are supposed to have an addiction specialist evaluate the patient before putting them on it.

But everything Qadgop said about it is true (as I would expect, as he knows more about addiction than the average doc).

Also, keep in mind that methadone for legitimate pain control is a very different issue (or should be) than methadone for addiction treatment.

[Qadgop the Mercotan]

he knows more about addiction than the average doc
More than the average junkie, too! ;)

that last fact really pisses off a lot of my patients

[Qadgop the Mercotan]

The state medical board will maintain a publicly available discipline history for him, but otherwise probably not, assuming he hasn't committed a crime or ethics violation due to the methadone/while on methadone or other opiate.
As I understand it, the doc never had any discipline, but rather presented himself to the board as someone with the disease of opiate addiction whose treatment included methadone maintenance.

The board did not want to run afoul of laws regarding discrimination against someone with an illness who is on an accepted treatment, so didn't deny him a license. He'd also not committed any violations of law or practice (that they were aware of) so had no grounds to discipline him on.

[LouisB]

When I delivered medications to nursing homes, I often had two or three stops where methadone was prescribed. It wasn't unusual for the recipients to meet me as close to the door as they could get and to follow me as closely as they could to their particular nursing station. Those patients weren't the least bit shy about letting me know when I was a few minutes late, either. Several nurses told me they could set their clocks by those patients; they knew to the minute when they were to receive their medication.

[Tom Tildrum]

More than the average junkie, too! ;)

that last fact really pisses off a lot of my patients

Hijacking now: QtM, have you watched any of Dr. Drew's Celebrity Rehab / Sober House shows? I get the impression that he really knows his addiction medicine, and he comes across as really credible, but I've wondered about the wisdom of trying to make TV shows out of these processes.

[Qadgop the Mercotan]

Hijacking now: QtM, have you watched any of Dr. Drew's Celebrity Rehab / Sober House shows? I get the impression that he really knows his addiction medicine, and he comes across as really credible, but I've wondered about the wisdom of trying to make TV shows out of these processes.
Never seen it. I lived it, so I see no need to view it.

Same reason I avoid ER dramas, Medical Practice dramas, and prison dramas.

[Cliffy]

but I've wondered about the wisdom of trying to make TV shows out of these processes.

I don't watch reality TV, but from what I've heard, Pinsky's rationale is that these people would never get help at all except for the fact that it gets them on TV.

--Cliffy

[Tom Tildrum]

Never seen it. I lived it, so I see no need to view it.

Same reason I avoid ER dramas, Medical Practice dramas, and prison dramas.

I hear that. I don't watch lawyer shows, for the same reason.

[Moirai]

Heh. My husband is the same way- never made it through a single episode of Law & Order, and his mom & sisters were always trying to get him to watch legal procedurals. He can't even watch cops shows, although I hope I can hook him with The Shield.

[Moirai]

I don't watch reality TV, but from what I've heard, Pinsky's rationale is that these people would never get help at all except for the fact that it gets them on TV.

--Cliffy

So they'll probably never stay sober. I think it's pretty sad to exploit the sick and dying that way. YMMV.

[cantara]

Sorry, Qadgop, I hadn't revisited the thread.

We're in Canada. She is attending the Wasser Pain Clinic at Mt Sinai in Toronto. Due to the fact that Methadone is an opioid, it is classified as a controlled substance here. Since the doctor has to be licenced to prescribe it and the pharmacy has to be licenced to dispense it, the two will necessarily be familiar with each other. The pharmacy that she has to use is located in the same hospital as the doctor. We'd had to sign some sort of form that indicated we understood it to be a controlled substance and that we would keep it locked up at all times.

We'd asked her neurologist if she could prescribe it, but she wasn't licenced to do so and wasn't interested in applying.

Overall it is a pain, and one that we'd rather do without.

She was also on a trial for a cannabinoid spray, but she did not find it effective or palatable. It tasted like filtered ashtray juice. There was a bunch of documentation required for that as well. For the record, neither of us imbibe in illegal drugs.

She is currently taking Neurontin, Gabapentin and Lyrica. She has considered trying to take the Tegretol again, as it was very effective for her. She had taken it for a month before we took her to the hospital where she stayed for a week for the allergic reaction.

[Really Not All That Bright]

Are you sure she is taking Neurontin and Gabapentin? The latter is the generic form of the former.

[Lemur866]

I hear that. I don't watch lawyer shows, for the same reason.

Yep, and I avoid Software Quality Assurance shows like the plague. I don't care how many awards they have I'll just end up yelling at the screen.

[chorpler]

As a result, one may get an opiate addict to be a semi-productive citizen while maintained on methadone. I actually know of a surgeon who practices (with the blessing of the Medical Board) while on methadone maintenance (I'd never go to him).

Semi-productive? If you can be a surgeon on methadone, I'd have to classify that as fully productive.

[Qadgop the Mercotan]

Semi-productive? If you can be a surgeon on methadone, I'd have to classify that as fully productive.
hey, he only worked 60 hours a week! ;)

[brujaja]

I've known a couple of people on methadone maintenance, and speaking purely anecdotally, I'd have to say that I think methadone makes some people stupid. I've seen continuous evidence of considerable degradation of critical thinking skills over time, and I suspect possibly hearing impairment as well.

Or maybe it's listening impairment.;)

But I do have a couple (http://www3.interscience.wiley.com/journal/120190793/abstract?CRETRY=1&SRETRY=0) of cites. (http://www.springerlink.com/content/amv8d2bg3x2rle8b/)

[chorpler]

I've known a couple of people on methadone maintenance, and speaking purely anecdotally, I'd have to say that I think methadone makes some people stupid. I've seen continuous evidence of considerable degradation of critical thinking skills over time, and I suspect possibly hearing impairment as well.

Or maybe it's listening impairment.;)

But I do have a couple (http://www3.interscience.wiley.com/journal/120190793/abstract?CRETRY=1&SRETRY=0) of cites. (http://www.springerlink.com/content/amv8d2bg3x2rle8b/)

If I'm reading right, the abstract on that first cite seems to indicate that it showed that methadone patients, particularly those with a history over alcoholism and heroin overdosing, have significant cognitive impairment compared to non-drug-users. No surprise there, but it doesn't seem to say much about methadone in and of itself. Ideally you'd want to test somebody's functioning before and after methadone treatment, but that could be a difficult study to perform.

The second cite is just bizarre. "Methadone treatment had no effect on craving or mood. Patients were unable to distinguish between methadone and placebo treatments." That doesn't make any sense at all. Either I'm completely misunderstanding what the abstract says, or the abstract is misrepresenting the study, or the study was incredibly poorly designed and executed. Any long-term opiate user is going to be able to tell the difference between a dose of methadone and a placebo, and methadone certainly has an effect on craving and mood.