Advocacy

Methadone Treatment of Addiction

Adoption Date:
April 1, 1990; rev. October 1, 2006

PUBLIC POLICY STATEMENT ON METHADONE TREATMENT OF ADDICTION

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Background

Opioid addiction is a complex disease involving physiological, psychologi¬cal, genetic, behavioral, and envi¬ronmen¬tal factors. It shares features of other drug addiction but often requires unique treatment strategies. No single treatment approach is effective in all cases. Methadone maintenance is effective and safe and is an integral part of addiction treatment; other opioid agonists are effective as well (see ASAM Public Policy Statement on Buprenorphine for Opioid Dependence and Withdrawal). Opioid agonist pharmacotherapy with methadone is especially useful for injection users of heroin. Ideally, methadone treatment for addiction includes behavioral, psychodynamic, and 12-step approaches combined with pharmacological interventions to provide a broad spectrum treat¬ment for opioid-addicted persons.

ASAM supports the following:

1. For many patients with opioid addiction, maintenance treatment with an opioid agonist is effective as a long-term modality. Discontinuation of methadone mainte¬nance carries substantial risk associated with relapse to intravenous drug use. Discontinuation of methadone maintenance should be attempted only when strongly desired by the rehabilitated patient, and conducted with adequate supervision and sup¬port. Individuals with addiction who have been discontinued from methadone maintenance should be carefully followed in a clinical setting and encour¬aged to participate in an ongoing program of recovery. In the event of relapse or impending relapse, additional therapeutic measures should be used including, when appropriate, prompt resumption of metha¬done maintenance treatment.

2. Methadone maintenance should include the following modalities in addition to the provision of the drug itself: psychological and vocational services, medical care, and counseling.

3. Arbitrary caps on the number of patients who can be treated by a physician, the dosage of medication which is allowed, or the duration of treatment with methadone are not supported by medical evidence and should not be imposed by law, regulation, or health insurance practices. Similarly, pre-determination of methadone dosage by program policy is inappropriate. Dosage should be individually determined by a well-trained clinician based on subjective and objective data and be adequate for the individual patient in all cases. This is particularly the case for pregnant women, for whom dosage should be carefully titrated to assure the elimination of illicit opioid use. Inadequate dosing, sometimes deriving from arbitrary low-dose policies, is associated with significant risk of relapse to illicit opioid use, placing the person with addiction into dangerous health circumstances, and, in the case of pregnant women, placing the fetus in significant danger.

4. Methadone treatment of addiction is a crucial resource to decrease the spread of HIV and Hepatitis B and C infection. Financial resources should be available to accommodate those seeking treatment; wait lists (developed in lieu of timely access to indicated methadone maintenance services) are potentially dangerous for the public health. All government and privately funded insurance plans should cover the costs of methadone treatment for addiction. Funding should also be available to train staff to provide good quality comprehensive care for persons with opioid addiction.

5. Methadone maintenance is an established treatment for pregnant opioid dependent patients and may be initiated at any time during pregnancy. Methadone discontinuation is rarely appropriate during pregnancy. When attempted, methadone discontinuation should be undertaken slowly under close monitoring and only in the second trimester. Individual dose determinations are more appropriate than arbitrary low-dose policies that often contribute to relapse to heroin use and to misuse of alcohol and other drugs during pregnancy. Provision of prenatal care, including high-risk maternal-fetal medicine care when indicated and available, is important for opioid addicted pregnant women. Proper nutrition, ongoing individual, family, or group counseling, to include prenatal and parenting classes, should be offered along with methadone maintenance.

6. Methadone patients need access to inpatient and outpatient treatment for medical, surgical, psychiatric, and non-opioid chemical dependency conditions without interruption of methadone maintenance. When methadone patients are referred to medically monitored or clinically managed addiction rehabilitation services, they should not be excluded from consideration for admission on the basis of their being prescribed a pharmacological therapy for addiction.

7. Persons incarcerated in jails or prisons who are under an established plan of care for opioid addiction that includes methadone maintenance should be able to continue the treatment plan for their chronic disease of addiction despite their legal status. Abrupt discontinuation can precipitate undesirable opioid withdrawal syndrome. (See ASAM Public Policy Statement on Access to Appropriate Detoxification Services for Persons Incarcerated in Prisons and Jails.”) Discontinuation of methadone treatment for incarcerated individuals carries all the public health risks of discontinuation of methadone in any other patients: the integrity of the treatment plan for the patient’s chronic disease of addiction should not be threatened by jailing or imprisonment.

8. The medical direction of methadone treatment programs for addiction should be provided by physicians who have received training in and can demonstrate expertise in addiction medicine. Medical Directors of methadone treatment programs who have not received certification in addiction medicine or addiction psychiatry should pursue such certification. Specialized training in addiction medicine provides the thorough working knowledge of both laboratory and clinical research which form the basis for methadone treatment of addiction.

9. Nurses and other health care professionals working in methadone treatment programs for addiction should receive special training and supervision in the medical and pharmacological aspects of addictive diseases and methadone treatment.

10. Federal, State, or institutional level regulations and guidelines which pertain to methadone treatment for addiction should emphasize performance-based standards of care, relying on clinical judgment and scientific data in the determination of treatment; encourage the development of new clinical strategies; promote individualized treatment planning; foster destigmatization and ensure patient rights.

11. Research related to methadone treatment should be supported, including work that will contribute to improved quality of methadone treatment of addiction.

12. Methadone can be an effective and safe medication utilized in treatment plans for acute and chronic pain, for both patients who have opioid addiction and patients not diagnosed with or needing services for addiction. When using methadone and other opioid analgesics for the treatment of health care conditions other than addiction, physicians must recognize the potential for misuse of the prescribed agent. It is the duty of the treating physician or other prescribing health care professional, as well as other clinical staff in the treatment team, to take all necessary steps to prescribe responsibly, to monitor patients carefully, and to carefully document their activities, so as to prevent and/or quickly identify opioid diversion by patients for uses unauthorized by and unintended by the prescriber.

3 comments

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  1. Kathleen Mar 05, 2014 - 01:15 PM

    What is the purpose of a 48 hour drug free before an intake?  Do you have to be in withdrawal to get accepted into a methadone program?  What are the federal guidelines ?  What are the clinics guidelines?  If you don't have a dirty urine screen will they dose you?  If you have a clean urine screen will they dose you or not. ?  I'm confused!  Thank you

  2. jill Nov 26, 2013 - 04:15 PM

    I have been at the Santa Rosa treatment center for over four years now.  I have been continuously sober and have obliged by the rules of the program.  I was told that I had small amounts of methadone in my system after a urine test that I know was not tampered with. I have been known to metabolize drugs very quickly.  Both my HMO know this and the clinic yet they felt it fair to take them all.  I am also told I am to be monitored fro 90 days during a urine test. Once more, I have been sober for over three years!  I have only tested dirty twice and both times it was because I couldn't get to the clinic to dose.   I lost all privileges for my three take homes which I felt was extremely unfair however I accepted this punishment since it is a very common occurrence in the clinic that people lose their take homes for reasons both beyond their control and for ones that are reasonable..  I am now going on a five day vacation that has been booked and paid for and they are refusing take aways for me to go and not be sick.  I find this completely ridiculous considering in the past three years I have taken over five trips and all of them have been over a week long.  One of them was a month to Australia.  The clinic knows me well and they know I need to take this trip or I lose almost a thousand dollars. After four years of sobriety they are denying me this and I find it completely inhumane and outrageous.  The doctor comes once a week to evaluate over fifty patients.  WHat rights do we have as addicts to have a life and still get medication?  I was addicted to Norcos only that were given by my doc for surgery and now I am trapped. IT is the worst decision I have ever made.

  3. Benjamin Phelps Apr 14, 2013 - 04:27 PM

    Hi,

         I wonder if we could get a policy statement regarding the withholding of dose for inability (note: not REFUSUAL) to give a urine sample on a randomly specified day? My clinic uses 100% observed drug screens, observed by a member of the opposite sex for men (a female nurse always observes). I have had a diagnosed case of paruresis since 1996, when I was first put on probation & it took 3 hours & more at times for me to finally be able to void. My current clinic's policy is that if you do not give a sample by the end of dosing hours, you do not get a dose. Period. I have asked about the purposes of this if it's not simply punitive. What I am told is that the half-life of methadone makes it unsafe to dose patients that "refuse" to give a sample. However, since instant tests are not used (our tests are sent off to a lab, meaning results won't be available for at least 1-2 days), this nullifies that reasoning. When I pointed that fact out, I was told that this topic would not be discussed, nor changed. What this policy amounts to is nothing more than a punitive, "Do as we tell you, or you'll be sent home to be sick tonight" policy without any further discussion. It demeans patients, it DESTROYS trust, & if the purpose is to be sure that a patient hasn't used illicit drugs & is trying to cover for it, then all that is required is the same old policy most clinics have, which is to auto-fail the test if no sample is submitted. However, fighting this battle is an uphill fight when I can find no statements of policy that decry the withholding of doses for reasons other than safety (i.e. - presenting to dose under the influence of drugs or alcohol). Thank you very much for your consideration.

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