Doctor's Column

Thanks to all of these fine doctors for participating . . .

Our Medical Advisory Board includes Dr. Vincent Dole, Rockefeller University; Herman Joseph, Ph. D., Research Scientist for the New York State Office of Alcoholism and Substance Abuse Services; Dr. Charles Schuster, Director of the University Psychiatric Center (UPC) and former head of NIDA, and his associate, Dr. John Hopper, Medical Director of UPC; Dr. Marc Shinderman, Director/Owner of Center for Addictive Problems (CAP) in Chicago; and Dr. Andrew Byrne, Australia, who has written two books about methadone.

If you have any questions you need answered by the doctors about methadone, here is the place to send them.     However, please read this first, or your question may not be answered.

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Dr. Column prior to October 1997 / Dr. Column Prior to April 1998 / Dr. Column Start November 1998

Back to the Table of Contents

More on Serum Levels - (October 1998, Vol. III, No. X)

Naltrexone-Related Deaths - (September 1998, Vol. III, No. IX)

Reluctant to Tell Employer About MMT - (August 1998, Vol. III, No. VIII)

Forced Withdrawal Letter - J. Thomas Payte, M.D. - (July 1998, Vol. III, No. VII)

Daughter on Methadone isTired & Anxious - (June 1998, Vol. III, No. VI)

Addiction vs Dependence - (May 1998, Vol. III, No. V) 

What to tell friends and family regarding MMT - (April 1998, Vol. III, No. IV)

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What to tell friends and family regarding MMT

Tell them as little as possible. Few can understand it, and most will not be supportive. Many "straight" people will reject you if they learn that you take methadone. They will immediately harp on you to be through with methadone at some point, which will have nothing to do with your capacity to do so without relapsing. If they are addicts, they will be jealous of your independence from them and the routine.

Do not discuss your dose--ever. It is no one's business. It will come back to haunt you one way or another. Tell them you do not want to know and you do not want anyone else to know. It does not mean anything. How you handle your life is what counts.

If you must discuss your treatment at all, discuss it in terms of your goals and progress (i.e. health, not using heroin, being pain free, school and vocational issues, improved relationships, etc.). If you must tell anyone, use the word "medication" and not "methadone." Bashing opiate use is a natural reflex for the ignorant; they cannot help themselves. Do not get into emotional arguments about "methadone." It does no good.

Sample Q&As
Q: When are you going to get off methadone?

A: When they find a better treatment or cure for heroin addiction. Research shows that those who withdraw from medication are dead, in jail or using heroin within 18 months. Why would anyone want to take those risks?

Q: Does that mean you will never get off of methadone?

A: My goals are (fill in the blank). Withdrawing from the treatment which gives me the opportunity to realize these goals seems self destructive to me. I know what life was like without medication; I may feel differently in the future. Who knows, maybe there will be something better than this medication one day? We can both look forward to that.

When others become animated and angry about it, and they will, do not get defensive. Just say, "I would have agreed with you before learning what I have and before experiencing the benefits of treatment." Offer to refer them to clinical research literature, addiction professionals who prescribe methadone, or personnel at your clinic or doctor's office if they want more answers beyond your little testimonial. Stick to what you know, which should be that your treatment is "a lifesaver for me personally. Isn't that wonderful?" If they are not willing to do any of these things and continue to pry and complain, you can observe (aloud or to yourself) that such persons' real interest is in your behaving like an addict again. You do not have to accommodate them.

Regarding being off heroin, no one wants to hear that you were ever ON HEROIN, in the first place. You do not get a gold star for publicly being off it. "I don't need it, why should you?" is their attitude. Everyone is vigilant for signs of your relapse once they know about your addiction history.

Many people actually think that it is a great idea to tell people about their methadone treatment. No one will really give a damn except to put you down for being an addict or worse if you are on methadone. All they care about is that you do not rock their boat with different ideas and new behaviors and that you continue to play out a role that confirms their microscopic egocentric world view. "Methadone Works!" does not do that for either the devoted addict or someone who has never had a problem with drugs. "Methadone doesn't Work!", confirmed by your dropping dead or being a failure, is much more self-affirming for both viewpoints. Some of these folks will subconsciously push and undermine you until you satisfy their limited expectations.

There are exceptions, of course. Use these guidelines always at first, and then choose whom you tell and what you tell carefully after you have stabilized in treatment and are feeling good about your progress. This is seldom before a year or two into treatment, in most cases.

Dr. Marc Shinderman
Center for Addictive Problems (CAP)
Chicago, Illinois

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Dependence vs Addiction


Many believe that addiction and physical dependence are the same thing. They are two very different issues. This has been demonstrated repeatedly in animal and human studies. Physical dependence may be a side effect from substance use, licit or illicit, taken for medical or recreational, self-medication purposes. It RARELY leads to addiction, which has to do with obsessive pursuit and abuse in the face of self-destructive consequences.

Neither many patients made physically dependent in the course of medical treatment nor lab animals that we make physically dependent in experiments, who do not have the "right stuff " (genetics or high stress environment), ultimately behave as addicts.

Physical dependence can be medically managed, fairly easily and inexpensively, if done so slowly, by most experts on an outpatient basis. Hospital treatment is usually not necessary. In addiction, it is usually not very effective for long.

NALTREXONE, Alcohol and Opiate abuse
Blocking development of physical dependence or some other responses that depend on stimulation of opiate (opioid) receptors in the brain with naltrexone is an attractive idea to many people. While it is common sense, addiction isn't that simple.

Naltrexone is a useful tool in the treatment of alcohol abuse. It might be useful in the treatment of some heroin addicts. It must be used in ways which protect patients from overdose and creation of high levels of drug craving, depression and diminished sexual interest, in my (research informed) opinion. Chronic administration may not be the way to accomplish all these goals.

Administration of naltrexone on a daily basis, for long periods, as is now possible through implants, depot injection or direct observation of oral dosing, will prevent physical dependence on opiates and many of the effects of alcohol that result in abuse. Used in this manner, it leads to increased craving and increased reaction to alcohol or opiates when the blockade is stopped. This means that a little will go a very long way, leading to disinhibited behavior, blackout in the case of alcoholism, or death, in the case of heroin, on very low doses of drug, once naltrexone blockade is removed. Long-term daily (or depot) use of naltrexone in alcohol treatment is inferior in these respects compared to its intermittent use, and I am wondering whether this might be the case in regard to the treatment of heroin addiction. The short term results might be better for chronic uninterrupted blockade, but the long term results may prove otherwise. It is something to watch. Frankly, I hope that I am wrong about this. If this chronic endorphin blockade does turn out to be a good intervention after all, using the depot injection, recently available somewhere (Naltrem) would be a simple procedure.

Dr. Marc Shinderman
Center for Addictive Problems (CAP)
Chicago, Illinois

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Daughter on Methadone isTired & Anxious

Dear Doctor,
My 24-year-old daughter has been on methadone for 6 months; her dose is 60-70. She is doing very well, but she is very tired all the time & has had problems staying up especially when she is in class. Are there any vitamins or nutritional programs to help her? She also has anxiety attacks when she sees people who she knew prior to her addiction; are there any anti-anxiety meds you would recommend? Thanks for your help.

Dear Mrs X,
Your daughter needs no special diet. She should have the same advice as any student in a similar position--good food, enough exercise, sound sleep and healthy social life are all important.

A certain level of anxiety in these circumstances is absolutely normal, and the best approach is to try to avoid the parties involved from her past life. In six months, she has apparently radically and successfully altered her lifestyle.

Drugs used for anxiety are often ineffective and some, like Valium, are habit forming and should be used with caution by people with addictive tendencies. If she has an underlying depression or other condition, she may need specific medication, and for this reason, she should consult with a physician who is familiar with dependency.

A full history and physical examination may reveal something which can be addressed to improve the anxiety. Some such problems are sometimes best not discussed with loved ones.

The dose is a technical matter between patient and doctor. A higher dose may help anxiety, but it may also worsen her lethargy or other effects. It is "always" possible to find a 'happy medium', but it may take some fine tuning. The "average" dose in good clinics around the world is now close to 100mg, so your daughter's dose of around 70mg is still in the low range. The maximum I use is 350 mg daily.

The use of other drugs is also important - with amphetamines, cocaine and alcohol being particular concerns in cases like this, whereas cannabis and tobacco seem to be less of a problem in such circumstances. This is not to say the latter should not be discouraged, as they should. Your daughter is now likely to lead a normal life as long as she treats her dependency seriously, seeking advice at the right time and getting the help she needs. She is likely to need methadone for certain periods, and she may be off methadone at other times.

You should treat her no differently than if she had high blood pressure, diabetes or another long-term condition. The one thing you must not do is pressure her to change her dose. If you are concerned about her condition, a second professional opinion is the most logical step, even if it means traveling to the next town.

I hope this is of assistance.

Dr Andrew Byrne,
General Practitioner, Drug and Alcohol,
75 Redfern Street, Redfern,
New South Wales, 2016, Australia
Tel (61 - 2) 9319 5524 Fax 9318 0631

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Forced Withdrawal Letter

       Sample letter to respond to efforts to force a probation/parole methadone patient into withdrawal solely for being on methadone.  This letter may be used in response to a threat that a patient must "detox" or be "revoked" and incarcerated.

       Such efforts are based on ignorance of the facts, leading to bias and serious discrimination.  Other issues involve forced medical decisions (practice of medicine), violations of civil rights, and denial of appropriate treatment for a medical disorder.  The letter can be adapted and is intended to educate and intimidate
    Re:        Forced disruption of methadone maintenance treatment by mandatory withdrawal
    Patient:  John Doe

Dear PO:

       On numerous occasions in the past, I have had patients who were in treatment for chronic opioid addiction involving the use of opioid agonists drugs such as methadone and LAAM, who were also on probation or parole.  In some cases continued treatment is incorporated into the terms and conditions of probation or parole to ensure continued medical treatment, supervision, and appropriate reporting to ensure compliance.  Experienced officers are often well aware of the advantages of maintenance pharmacotherapy in terms of fostering employment, elimination of criminal activities, drug use, improved health, and lowered rates of relapse and recidivism.

       However some officers may not be familiar with the considerable body of knowledge, scientific and clinical research that establish opioid maintenance pharmacotherapy as the most effective treatment for chronic opioid addiction.  Addiction has been clearly demonstrated to be a chronic, progressive, relapsing and often (if untreated) fatal disease.  Opioid maintenance is a medical treatment utilizing effective pharmacological agents (medications, primarily methadone and LAAM) to correct, stabilize, and normalize the disease process  but not to "cure" the disease.  opioid maintenance treatment has been shown to be safe and effective in terms of dramatic reduction in death rates, stopping illicit drug use, elimination of criminal activity, reduction in spread of hepatitis B and C as well as HIV disease.  Social function, mental and physical health, and employment are enhanced.

 Forced withdrawal from opioid maintenance treatment is associated with a greater than 90% relapse rate to illicit opioid drug use.  Relapse carries added risks of overdose, HIV infection, hepatitis, return to criminal activities, as well as the violation of specific terms of probation or parole.  The choice of opioid maintenance treatment as a treatment modality is a medical decision made by the physician in consultation with the patient.  Any decision to withdraw from methadone is also a medical decision made with considerable caution based on the patient's strong wishes to withdraw as well as progress in treatment and the degree of stability in such domains as employment, social stability, etc. that will support ongoing recovery and abstinence.

 At times opioid maintenance treatment patients who are doing well in treatment and not otherwise in any violation of terms and conditions, are subject to efforts to force discontinuation of treatment for their addiction with threats to revoke and send them to prison.  These efforts appear to be based on bias and prejudice toward opioid maintenance treatment fostered by a lack of knowledge relating to addictive disease and the various treatment modalities, including opioid maintenance treatment.

 Being in opioid maintenance treatment does not constitute a basis for relaxation of any standards in relation to specific terms and conditions of probation/parole.  Those in violation and facing revocation will be afforded withdrawal based on conditions in effect.  My concern is in the cases where continued effective and essential treatment is threatened based on objections to the treatment modality.  The objection appears to be based on the use of a medication (in this case an orally effective, long-acting opioid agonist such as methadone or LAAM) to relieve or correct a neuro-biological defect that does not lead to a "cure."  There are many examples in the practice of medicine where treatments of a host of disorders, such as diabetes, hypertension, allergies, hormone deficiencies involving medication that stabilize, comfort and relieve but do not "cure."

 I view these efforts with considerable alarm over the exertion of very questionable authority to deny an individual with a medical disease (chronic opioid addiction) the right to get the most effective, safe and legitimate treatment available.  This may be seen as a violation of civil rights and provisions of the Americans with Disabilities Act that comes dangerously close to the practice of medicine without a license.  The disruption of treatment carries very real risks and potential harm and very significant losses, far beyond the relapse to illicit drug use with impact on the individual, his family, and the community at large.

 Medically supervised withdrawal (MSW) from methadone maintenance is a medical procedure that must be ordered by a physician and done with full informed consent of the patient.  MSW cannot be mandated in disregard of the health and safety of the individual and the community.  On grounds of medical judgment, I refuse to perform this procedure in the absence of sound indications that would support a reasonable chance of a successful outcome.

 By Federal law, patients have the right to a MSW on request.  This procedure is allowed when evidence suggests that the patient strongly desires the procedure and understands the risks.  When the patient's request for MSW is in response to external pressures and/or threats the procedure is done only against medical advice (AMA) with full documentation of the circumstances.  The patient signs a form acknowledging the AMA conditions, that there is pressure to stop opioid maintenance treatment, and that the patient is aware of the risks and consequences of this procedure
 Consultation with legal counsel has assured me that any restrictions imposed upon an opioid maintenance treatment patient by individual officers of probation or parole departments may be seen as a violation of constitutional rights under US Section 1983 and the Americans with Disabilities Act, among others.

 If continued appropriate treatment for his chronic opioid addiction is assured, our program will cooperate fully with officials to ensure compliance and his participation in treatment to facilitate rehabilitation and development as a responsible, productive, and law-abiding citizen.

 The treatment proposed is continued methadone or other agonist treatment for as long as the patient continues to benefit from treatment, is at risk of relapse, and desires to continue.  Getting off methadone is never a criterion of success.  However, periodic evaluations are made to determine the feasibility of a change to a maintenance-to- abstinence" track when appropriate and strongly desired by the patient.  In many cases two  or more years are needed for stabilization and to reach a point where withdrawal from methadone can be accomplished and the resources are in place to maintain a drug-free life.  Some patients will require very long term if not life-long treatment, while others are candidates for abstinence based continuing care.
 Editor's Note: I have had several people ask what they can do when a probation/parole officer tells them to get off methadone. Sincere thanks to Dr. J. Thomas Payte for allowing us to reprint this excellent letter to help them out.

 For those of you who have internet access, Dr. Payte has a web site at:  It is well worth checking out, if only for the letters he has online.

 To mention just a couple of items to his credit, Dr. Payte was a recipient of the Nyswander-Dole Award (The Marie Award) in 1992, he is the editor of the recent Journal of Maintenance in the Addictions published by the Haworth Press, and he has a patient-oriented methadone maintenance clinic:  3701 W. Commerce Street, San Antonio TX 78207

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Reluctant to Tell Prospective Employer About MMT

Dear Doctor,

 I have been on methadone since September 1997. It has  worked FANTASTICALLY!!  I have not used even once since I started.   We just bought a new home, and I am ready to start looking for a part time job to help out with the bills.  I am very reluctant to tell any prospective employer that I am on the program.

 My question is this:  what socially-accepted affliction can I tell them I have that requires me to go to the clinic every morning as well as group every Tuesday afternoon.  I am not willing to give up my Tuesday groups.  I have made very good friends with them and the counselor.  I was thinking I could say I have diabetes, but they would see me eating candy and especially drinking chocolate milk (which I now crave).  Any thoughts?
Thanks,  DS 

Dear DS,

 Frankly, I would not lie.  I would not tell them anything, personally.  If you must lie, make it a whopper.  You might say that this is a religious meeting.  Religion is not discussed and judged as much as are medical issues.   A religious excuse might be perceived as something both benign and not to be messed with by an employer.  The other lie that you might like is "eating disorder" treatment.

Good Luck.
Dr. Marc Shinderman
Center for Addictive Problems (CAP)
Chicago, Illinois

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Naltrexone-Related Deaths

Dr. Andrew Byrne

 In June, I learned of three Sydney drug users who had been through rapid detox and then died afterwards.  All three stopped their naltrexone and overdosed on narcotics.  I know that two of these cases will be referred to the coroner.  One may have been an intentional suicide.

 It is very worrying to have three deaths in such a short period and in the one small area.  I am concerned that these may not be isolated.  All of these patients were repeatedly informed of the dangers of using even small amounts of heroin after the rapid detox procedure.  At least two signed consent forms to this effect.  Depression played a role in at least two of these patients who were both originally treated in different cities to  their place of residence.  Only one patient was in a funded trial supervised by an ethics committee, while the others paid for private treatment elsewhere in Australia and overseas.

 One patient died 10 days after the procedure, one 6 months and the third an unknown 'number of weeks' after detox.  One had a general anaesthetic while the other two had sedation.  One patient was a 40-year-old registered nurse who had been stable on methadone for 8 years previously.

 We must all advise extreme caution when dealing with a modality which is not yet established.  Would we allow a relative to be treated with a new intervention of unknown safety or effectiveness?  My feeling is that more information needs to be obtained on the patients who have already been treated before embarking on further trials of this manoeuvre.

 It may be that Miotto's study published last year was not exceptional.  They found that of 81 traditional detox patients who were prescribed naltrexone, 13 had overdosed within a year and 4 were dead.  Another patient had attempted suicide by jumping from a moving vehicle.

 There are still many unanswered questions about naltrexone, the most pertinent being, "is it safe and is it effective."  The evidence in favour2 of these is still very slender.  A recent review of a large number of studies3 provides little encouragement for those who believe that this is a major advance.

 1Miotto K, McCann MJ, Rawson RA, Frosch D, Ling W.   Overdose, suicide attempts and death among a cohort of naltrexone- treated opioid addicts.  Drug and Alcohol Dependence (1997) 45:131-134.
 2Spelling is correct--Australia
 3O'Connor PG, Kosten TR. Rapid and Ultrarapid Opioid Detoxification Techniques. 1998 JAMA 279;3:229-234.

          Dr. Andrew Byrne,
          General Practitioner, Drug and Alcohol,
          75 Redfern Street,
          New South Wales, 2016,
          Tel (61 - 2) 9319 5524  Fax 9318 0631

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More on Serum Levels

Serum Levels
Active & Inactive Methadone

 People are always asking me about serum levels.  Usually they tell you something useful, but not always. . .

 American methadone is a 50/50 mixture of active and inactive forms.  Swiss sometimes use the pure form that has only active methadone, as well as the mixed (racemic) product used for maintenance in the US.

 These are called different names in different languages but are named for the right-handed or left-handed nature of the way the molecule transmits light.  What is important is that only one of these methadone forms is biologically active.

 Our traditional serum level lab tests are based on adding the total methadone, both right- and left-handed.  Combined values, which equal 450 ng/ml or greater are cited as being the minimum necessary for good treatment and abolishing craving.

 The problem is that some patients  metabolize methadone in a way that allows the 50/50 ratio of inactive/active methadone to vary widely.  Some patients can have far too little of active methadone ("R" methadone) but still have serum levels in the normal range.

 Others can be comfortable with low serum methadone test results because they have larger than average "R" methadone fractions in their system.  In patients whose active/inactive (R/S) methadone ratio is less than .67 (=40 percent active methadone), Swiss clinicians (JJD) have observed signs and symptoms of withdrawal and emergence of craving although their total methadone serum level would appear to be adequate.
 In the US, we need to medicate patients based on clinical signs and symptoms more than on serum levels.  Tests which measure the two isomers are now expensive, and our literature does not yet reflect broad clinical experience with their use.  Pure "active" methadone, which is usually dosed at fifty percent of the dose of our methadone, is unavailable here (and costly, if it were).

Abstract information:  European Journal of Clinical Pharmacology ISSN: 0031-6970 (printed version) ISSN: 1432-1041 (electronic version).

 Although of small amplitude (16%), this decrease confirms previously described adaptive changes in methadone pharmacokinetics during racemic methadone maintenance treatment and may necessitate, in some patients, a dose  adjustment.

Dr. Marc Shinderman
Center for Addictive Problems (CAP)
Chicago, Illinois

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