Doctor's Column

Dr. Marc Shinderman, Center for Addictive Problems (CAP), has recently joined our Medical Advisory Board. We would like to take this opportunity to thank him for his support.

If you have any questions you need answered by the doctor about methadone, here is the place to send them.

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All Questions from issues of Methadone Today October 1997 and later

Underdosed and Craving (March 1997, Vol. II, No. III Methadone Today)

Methadone and Health (April 1997, Vol. II, No. IV Methadone Today)

More to Underdosed (May 1997, Vol. II, No. V Methadone Today)

How Long Should I Stay on Methadone? (June 1997, Vol. II, No. VI Methadone Today)

Serum Levels and Split Dosing (July 1997, Vol. II, No. VII Methadone Today)
Thanks to Dr. Marc Shinderman of Center for Addictive Problems, who has joined our Medical Advisory Board.

Not Able to Sleep When Detoxing (August 1997, Vol. II, No. VIII Methadone Today)

Serum Level Testing (September 1997, Vol II, No. IX Methadone Today)

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Ms. Francisco,

As the Medical Director at UPC Jefferson Avenue Research Clinic, I would like to congratulate you on both Methadone Today as well as your web site. The work you are doing is very valuable. If you would be interested, Dr. Schuster and I would be willing to answer medical and pharmacologic questions about methadone for Methadone Today.

You could solicit questions from readers and we could answer one or two questions from a small group that you could select. I recognize that there are pros and cons for doing this. Clearly, your publication is for and by patients and we would not want to detract from this mission. Let us know if you are interested. Again, we completely understand if there are reasons why you might not want to take us up on this offer. Sincerely, John Hopper

Assistant Professor, Internal Medicine, Pediatrics, Psychiatry
Medical Director, Clinical Research Division on Substance Abuse, Wayne State University

We were thrilled to receive this offer from Dr. Hopper and Dr. Schuster, and we are pleased to announce that we will feature a "Dear Doctor Column" to answer medical and pharmacologic questions. John Hopper, M.D., will answer your question this month. Dr. Charles Schuster and Herman Joseph, Ph.D. will also answer questions for us. Please send questions and/or comments to Methadone Today.

Underdosed and Craving

Dear Doctor:
I am a patient in a methadone clinic and have been for several years, but I only recently discovered that a proper dose should take away cravings for opiates. I thought that when withdrawal symptoms were taken care of, I should stop increasing the dose even though cravings continued. Although I have not used any other opiates, I don't believe I have been properly dosed all this time. In fact, I started drinking several times because I felt cravings but was afraid to start using drugs again. I haven't had a drink in a long time; I am afraid to drink too, because I just don't quit. This is no way to live if a higher dose would stop the cravings.

I tried to detox several times because other people wanted me to, but I was unable to do so. I am scared to death to try it again because having the cravings that I do at this dose (65mg), I know I would return to other opiates if I was not on methadone maintenance. And anytime I bring up an increase to the doctor, he wants to know, "Why don't you get off this junk." Medication that saved my life is not "junk."

From reading I have done, most patients are very conservative and don't ask for a sufficient dose. As for myself, I am afraid to ask for an increase because I have been in the program so long being a good little girl, keeping my dose down, and I don't know how to approach the issue. Do you have any advice for me? Thanks - Underdosed and craving

Dear U & C:
"Craving" is probably one of the most important but least understood aspects of drug dependence. There can be many causes of craving. Some cravings may be "physiologic" and respond to changes in methadone doses, some may be "conditioned", or learned, and may require other methods of "treatment". Certain situations may remind you of your prior opiate use and trigger cravings. Some common triggers are seeing a friend with whom you used to use drugs, passing a place where you used to buy drugs, or having enough cash that you could buy opiates.

Since you have been in treatment a number of years, you might start to address this by keeping a "craving record". In this log, you can record the date, time, and situation that precipitated the craving. You could also add a "severity" scale (e.g. mild, moderate, severe). Keeping this type of diary may give you significant insight into your cravings. Are there situations that might be avoidable or modifiable? Is there a particular pattern? Reviewing this record with your counselors and clinicians could allow you to further your treatment plans (medication or otherwise). - John Hopper, M.D.

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Methadone and Health

Dear Doctor:
I'd like to ask you a question regarding methadone and health. I have been taking methadone for 13 years, and I am on 100mg (always was on 100). Are there any known negative side effects of long-term use? The other question concerns weight. When I ask doctors, I get mostly, "I don't know." I blew up when I went on methadone, and much of my weight appears to be water. Not only do I perspire profusely, but my weight can vary 10 to 15 lbs. in a day! What's the story?

Dear Patient:
Your concerns about methadone's safety and side effects are understandable. Like all drugs, methadone has both common and uncommon side effects. Individual differences in response are very important, but for the vast majority of patients (including pregnant women and their offspring), methadone will have no significant long-term side effects. This can be said based on about thirty years of experience with methadone programs in this country. Methadone mimics the natural body chemistry of endorphines so its safety is not surprising.

Water retention and weight gain on methadone are not unusual. Many people gain weight from better eating habits. Your metabolism may also slow down, and this can result in some weight gain. All opiates have an "antidiuretic effect" which causes water retention. For some people, the water gain is more pronounced. Wide swings in weight could indicate another problem. You should definitely discuss water weight gain with your doctor if you also have shortness of breath, leg swelling, or swelling in the abdomen.

Your body is able to gradually adjust to many of methadone's effects. Unfortunately, if you have profuse sweating on methadone, this will usually persist. Your best bet in this case is to try to modify things like the types of clothes you wear, the antiperspirant you use, or the types of skin care products (like powder) that you put on.

I would be interested to hear from readers on how they have dealt with sweating.

Dr. John Hopper, M.D.

Assistant Professor, Internal Medicine,
Pediatrics, Psychiatry
Medical Director, Clinical Research Division on Substance Abuse, Wayne State University

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More to Underdosed

To the patient who has been in treatment for several years and feels that she has been under dosed all this time, Dr. Andrew Byrne, of Australia, added a few comments to what Dr. Hopper told us:

Dear "Under dosed",

I was interested in the doctor's comments on cravings and the complexity of such feeling. In my practice, we routinely order blood methadone levels on patients with questions like yours. You have been on 65mg for some time, I gather, and still have periods where you get cravings. Professor Dole, who originated methadone treatment, says that to avoid cravings, the blood methadone levels should not drop below 200 ng/ml. It is very likely that your levels (24 hours after a dose) are well below this. Some of our patients in whom the question arose had levels which were not even detectable.

The long and short is very simple. Assuming that you have no signs of toxicity (pinned pupils, nodding, sleepiness, etc.) then a dose increase is appropriate. Your dose is about average for our practice, meaning that half of our patients take more. We have people on as low as 2.5mg and as high as 300mg daily. It is incredible that some people on 50mg have higher blood levels that those on 150mg. Best of luck with your decisions...but remember, if you are going to all the rigors of being on MMT, then you might as well be on the dose which makes you feel and function at your best.

Andrew Byrne (Aussie MD, Sydney)
Many thanks to Dr. Byrne for allowing us to use his comments.
Beth Francisco, Editor & Publisher, Methadone Today

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How Long Should I Stay on Methadone?

Dear Doctor:

I am fairly new to a methadone clinic and relatively young. How long do you suggest that I remain in methadone maintenance treatment? Terry
Dear Terry,

Most people whether new to methadone or not, wonder how long they should remain in maintenance treatment. Because treatment is individualized for your addiction, the decisions of if and when to come off are unique to you. The Health and Human Services Administration recognizes this, and states the following on the FDA 2635 form that you signed on enrolling in treatment: "I realize that for some patients narcotic treatment may continue for relatively long periods of time, but that periodic consideration shall be given concerning my complete withdrawal from the use of all narcotic drugs."

I would encourage you to look at these areas to decide when you are ready to try a reduced dose:

Have you stopped using all illicit opiates?
Have you established supportive/stable interactions with non-drug using peers?
Have you put you life together in dimensions such as family, work, spiritual, legal, medical, psychological?
Have you developed appropriate (non-drug using) mechanisms for dealing with potential "roadblocks" to recovery (e.g. depression, anxiety, anger, disputes, health problems)?

Some people will get to the point of reducing sooner than others. The length of time you were addicted and your relative well-being in mind, body, and spirit may determine how long you will be on methadone. I hope this is helpful, good luck in your recovery!

Dr. John Hopper, M.D.
Assistant Professor, Internal Medicine,
Pediatrics, Psychiatry
Medical Director, Clinical Research Division on Substance Abuse, Wayne State University

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Serum Levels & Split Dosing
Dr. Marc Shinderman, Center for Addictive Problems (CAP) - Chicago

Dear Doctor:
About three months ago, I got on a methadone maintenance program. Instead of being started at the standard 40mg, I was started on 20mg--I think because I was so high when I went in there, I'm not sure. Anyway, 20mg was fine for the first week, then I started getting sick in the morning. I kept increasing my dose 10mg at a time, and the same thing would happen. The dose would hold me fine for about 5 days, then I would start waking up sick. I was up to 100mg, and I was still waking up sick in the morning. I dose at 8:00 a.m., and by 3:00 a.m. the next morning, I'm sick as a dog.

When I wanted to go up again, they didn't believe that I was sick, so they drew some blood to see what my methadone blood level was. As I suspected, it was low. They told me that because of my metabolism, I'm a "fast metabolizer", and my body is running though the methadone "very quickly". The people at the clinic tell me that if I keep going up, I will eventually find a dose that holds me for the full 24 hours.

At the dose I'm at, already I can't take the constipation. I have to take six stool softeners, a gallon of water, and 1-2 enemas A DAY if I ever want to have a bowel movement.

I never had so much trouble on heroin. My psychiatrist (who, by the way, was the medical director of the same clinic from '75-'85) tells me that no matter what dose I go up to, my body will adjust, and I'll ALWAYS get sick in the morning. He recommended that I detox. I went down to 95mg about three days ago. Mind you, I was already getting sick on 100mg/day. From about 2:00 a.m. until my dose, I'm in full-fledged withdrawal.

What should I do? Is it true that I won't ever reach a dose that holds me? The catch-22 is that at the dose I'm on, I can't tolerate the side effects, but it's not holding me 24 hours. I can't go up; I can't go down. Because my metabolism is so fast, I requested a "split dose", but because I'm new to the clinic, they won't trust me with any evening take-homes. I'm so screwed. I need some advice. I'm much worse off than when I was using heroin: Now, I have to go through withdrawal every single day of my life. I want to blow my head off. - Matt

Dear Matt:

Relax. Your problems are not impossible ones.

1. Senna or Sennatural or Senekot is the best stool softener for most of my patients. Take it. Get your dose, divided.

2. What we do at CAP, in such cases, is divide the dose in two or three portions. At first, I would advise 50mg in the morning and 50mg as long after as you can handle, feeling comfortable. The first day, I would recommend 100 mg as usual, 50 mg 12 hours later, then 50mg the next morning and afternoon from then on.

3. You should protest it to the regulatory agency in the state and FDA and protest it to the people who give the MD his license if they do not respond adequately. If the clinic says that this is against the "rules," they are mistaken or they are talking about their rules, which should not prevent good medical treatment. The doctor can ask the regulators for an exception due to your medical situation. The low serum level is in the record. Your complaint of constipation is serious and not unique.

If they do not trust you, they should arrange for you to drink your medication 2 times a day, observed. This anti-patient treatment is what drives patients back to smack. It is unethical. The "rules" cannot be applied with clinical success to every person, and the FDA will grant exceptions to them.

4. You should go to a clinic where they give you a take home split dose. As a second, very stupid, but possible solution, you should go to a clinic where you could dose observed twice a day, 6 hours apart, or more. (At CAP we medicate 5:30 am to 7 pm, for example). We get exceptions for split doses for new patients every few weeks or so. We do it to get their serum levels up and keep them from using heroin. We think that is the main job that we have. Everything else is secondary. Being able to hold off on your dose, from time to time, may help with the constipation (along with the Senna and water).

5. Try LAAM at 120 to 140 mg. Yes, I said LAAM, ORLAAM. Some patients like it better than methadone. You may be one of them and it is worth a shot. You are near to relapse--a better choice than what you feel like doing: ("I want to blow my head off"). Use all the tools available to hold on to your health. LAAM is one. Why? Keep reading.

a. you only go to the clinic 3x a week (if it is a good clinic, you can choose to see your counselor or get what you need from it, anytime. If it is lousy, as I infer from their mistreatment of you, enjoy the break from their ignorance.

b. it may not give you constipation.

c. it holds fast metabolizers longer.

d if you do use opiates, it has no consequence on your clinic schedule. You come 3 days a week, using or not.

e. LAAM will cost the clinic 300 percent more than methadone, which might give you some twisted pleasure. You deserve some revenge.

You ask if it is true that you won't ever reach a dose that holds you. No, that is ridiculous. You may need to see an actual MMT professional physician who knows how to medicate patients. You have no real problem that common sense cannot deal with. Hold on.

While you are waiting for rational care you can try the dopey but practical stop gap measures of taking meds that will help you on the screwy regime that you are on (100mg/D single dose).

You can take a few tabs of over-the-counter Tagamet, the generic is cimetadine, and you can use a small dose of clonidine at the time when you feel that you are feeling "funky" or might otherwise describe the moment that you know that you will not be feeling great in an hour or two. If you take clonidine when you feel okay or 4 hours before your dose or 8 hours after, it can make you pass out. You should have an MD prescribing the clonidine and she will advise you of the risks, which are real. Do not take clonidine from a friend. Your brains CAN "BLOW OUT" if you take a lot for a few weeks, and then stop, suddenly. It is not candy. It is not benzos. It is blood pressure medication. It works.

Finally, if none of the above works out, you should come to our clinic, and we will transfer you back as soon as possible--stabilized. What you have to lose in relapse or blowing your brains out is well worth whatever it takes to spend a month or two in Chicago.

(Tell me about what medications, alcohol or drugs that you may be taking now. If "some," there may be different answers than the ones above. Ditto for hepatitis or anti HIV meds.) Dr. Marc Shinderman, Center for Addictive Problems (CAP)

Editor's Note: We are delighted that Dr. Shinderman has joined our Medical Advisory Board. His should be the standard for all methadone clinics. The patients are the most important people there, and it is not an inconvenience to them to get the patient properly and correctly dosed. Thank you, Dr. Shinderman - Beth Francisco, Editor

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Not Able to Sleep When Detoxing

Dear Doctor:
I have tried many, many times to come off of methadone, but I always face the same two major obstacles--not being able to sleep and the feeling of a need to get high again. What's going on, and what do you suggest that I try? Signed C.O.

Dear C.O.:
Each person has a unique set of issues to deal with when trying to come off methadone. Your problems with sleep and wanting to "get high" are tough to address without knowing you as a person. Some of the things I would like to know more about include: What are your sleep habits and patterns? Over what period of time did you taper your dose before wanting to get high? Are you using any other opiates while on methadone? Do you feel like getting high when you are on your maintenance dose? If so, when and how often?

I think these are all important issues to discuss with your counselor and physician. The issue of wanting to get high is particularly hard to address without knowing more about you. Something that many counselors emphasize for all types of distressing symptoms is to keep a personal log of when these symptoms occur, how severe, and what are the possible triggers.

I can say a few things, in general, about not being able to sleep. Untreated or unrecognized anxiety and depression can be causes of poor sleep. In addition, having a regular and stable pattern of sleep habits is necessary to ensure restful sleep after tapering methadone. This includes waking up at the same time each day (weekends as well), using the bedroom only for sleep and sex (not drug use), and not spending too long lying in bed waiting to fall asleep. These are a few general principles for all people with sleep problems. Hopefully these ideas can lead to some productive discussions with your counselor or others. - Dr. John Hopper

Dr. John Hopper, M.D.
Assistant Professor, Internal Medicine,
Pediatrics, Psychiatry
Medical Director, Clinical Research Division on Substance Abuse, Wayne State University

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Serum Level Testing

Dear Doctor:

My clinic thinks they have to take blood twice when checking serum levels. From what I have read, this is not necessary. Also, I have heard there is a test that doesn't do much good and/or is used against the patient. Can you clarify these issues for us? - Wondering

Dear Wondering:

The only lab that can be trusted is the Quest LAB which is in San Diego; it used to be called Nichols, then MetPath Corning, and now "Quest." They are expensive at $30 to $40, per test.

Peak levels are useless to me. I prefer observing the effect of a dose on a patient three or four hours after dosing and getting a serum methadone trough level (24 hours after last dose). If the patient shows sedation or intoxication at 4 hours but has a low serum level and complains of withdrawal, I infer that they are fast metabolizers, needing a split dose. If there is no intoxication, with complaints of withdrawal or continued illicit drug use and a low serum methadone trough level, a substantial increase is required.

I am aware of an inexpensive test from another San Diego Lab which does not measure serum levels in the customary way and presents results as: "25ng/ml is low - 400 ng/ml is high." There is no useful conversion factor between this and the traditional method, where 400 ng/ml at 24 hours after dosing is the LOWEST level considered adequate to reduce craving. Citing the results of this test and using the traditional numbers, patients can be denied adequate treatment even by well-intentioned clinicians. What this test calls "high" is actually low by numbers cited in the CSAT literature.

Beware of any test that does not come from the Quest Lab. I have had bizarre results with every other lab that I have tried. Please let the advocates know that the labs used can have a big difference on outcome.

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