Methadone Today

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Volume II, Issue 7 (July 1997)

When The Dose Is Not Holding The Patient - (TIP) Series #1, State Methadone Treatment Guidelines

The Good News Is. . . .by Jackson

The Bad News Is. . . .NAMA

If The Other Shoe Fits - by Ken T.

NAMA's Methadone Awareness Test

Briefly Speaking - Short items about drugs in history

Please Note - New information and reminders

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When the Dose is not Holding the Patient

A variety of complaints may introduce the case for more methadone, for example, "I wake up sick; I have a strong urge to fix; I am fixing." There are a number of reasons why the patient who was stable may be having problems in relation to dose.
Perhaps the most frequent cause is the ingestion of other substances, especially alcohol. Any drug that stimulates the liver's microsomal enzyme-oxidizing system may accelerate the metabolism of methadone. Barbiturates and other sedative-hypnotics may also produce this effect.

Specific drugs known to accelerate methadone metabolism, and at times, to precipitate abstinence syndrome (AS), include rifampin (Tong et al. 1981), phenytoin (Dilantin) (Kreek 1978), and carbamazepine (Tegretol). . . .A. J. Saxon (1989) suggested that valproic acid, unlike other anticonvulsants, has no effect on methadone metabolism. Although his opinion was based on only two cases, consideration of valproic acid would be justified when the clinician faces a choice between seizures or abstinence.

Inadvertent administration of opioid agonist/antagonist drugs can also precipitate AS by an entirely different mechanism [opioids displaced from receptors].

Environmental changes and other stresses can cause the patient to perceive that the dose is not adequate and to experience increased drug craving. Events that increase the availability of drugs, such as another addict moving in at home or a "connection" opening nearby, can intensify drug craving. Dose increases may be quite appropriate in such cases, although efforts should focus on resolving the offending situation rather than [just] relying on more methadone.

In the absence of medication or environmental contributions and polysubstance abuse in an apparently destabilized methadone maintenance patient, plasma level determinations should be considered. Figure 3 is an approximation of a typical 24-hour blood plasma curve based on established steady-state maintenance, with the zero-hour dose approximately 24 hours after the previous dose.

At present, 150 ng/ml is generally accepted as the lowest level that will maintain steady-state effect (Dole 1988). The optimum 24-hour mean plasma level may be more in the 400 ng/ml range (Goldstein pers. Com. 1991; Kreek 1973; Tennant 1987; Wolff et al. 1991). Loimer and colleagues (1991 suggest that "methadone plasma concentrations of 400 ng/ml are necessary to suppress any further opiate action and to provide stabilized maintenance. The optimum dose is the level at which there is adequate methadone to provide constant availability to the opiate receptors. The data for the lower curve in figure 3 are based on experience with an actual patient on 80 mg of methadone daily who persistently complained of waking up sick and having drug hunger. This patient responded to an increase in dose.

Figure 4 illustrates experience with a patient with low zero-and 24-hour methadone plasma levels with a peak that was within normal values but was high in relation to the very low trough levels. In the figure, the peak is more than three times the nadir and the absorption and elimination portions of the curve are much steeper, indicating a rapid change in state. In such a clinical situation, it is likely that the rate of change is as important as, or more important than, the numeric values themselves (see fig. 4).

If the dose is increased in an effort to bring up the 0-24-hour level, the peak level may be excessive, thus exaggerating the abnormal curve. Assuming that the cause for the rapid elimination is not apparent (drugs, urinary pH, etc.), a "split dose" may be indicated to avoid having the patient somewhat over medicated for a few hours, feeling normal for a while and still feeling bad or waking up sick later. Figure 4 shows the split-dose desired responses in two so-called "fast metabolizers." In both cases, the total dose is the same as for a 24-hour period and the area under the curve is essentially unchanged. What changes is that both the low nadir and the high peak are eliminated, resulting in a smoother clinical response associated with the flattening of the curve.

Excretion of methadone via the kidneys is pH dependent. Studies have shown that by altering the pH from very acid to very alkaline, the half-life of methadone may vary from less than 18 hours to greater than 40 hours (Nilsson et al. 1982). The clinical significance of more modest variation in urinary pH has not been demonstrated but probably deserves attention in evaluating the patient who is not getting a 24-hour effect from the methadone.

This information comes from the Treatment Improvement Protocol (TIP) Series #1, State Methadone Treatment Guidelines, from the Department of Health and Human Services. This 222 pg. book can be obtained by calling (800) SAY-NOTO and asking for TIP #1

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donated by Jackson

At my old clinic a guy came screeching in and ran inside to dose as it was near closing time, and they locked that door ruthlessly as the Florida State Trooper behind him tried to follow, only to be kicked out! Sizzle!!! He was told that he would have to wait until the patient was finished inside and ticket him when he came out. I'll bet he all of a sudden had to see his counselor that day!! They told the cop that this was a Federally Protected facility and confidentiality did not allow law enforcement inside? I was proud to be on that clinic.. .It was the only Real One!! I've been on 4-5 clinics.

What a great story! It sure made my day. Of course the man was speeding if the clinic was about to close. It is not a great story simply because the law was kept out (the man was speeding)--it is, however a great story because this patient was able to dose before the law got their hands on him, and the clinic staff protected this patient--what would your clinic do?
What I want to do with the newsletter is have a regular feature which gives a short story about something great a clinic has done, then on the other side, give an equally egregious example of things that clinics or others do TO patients instead of FOR patients.

If anybody has a good story (or bad story, whichever the case may be), let me know; send it to us at Methadone Today, P.O. Box 164, Davison, MI 48423-0164.

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A methadone patient, Lynn, is also a pain patient who has cancer and was arrested about 4 years ago for paraphernalia (a Bong Pipe that is also a statue of Pegasus) that had never been used. In fact, she just bought it because she liked horses.

When the judge found out she was on methadone, he insisted that she be put on probation and that a condition of her probation be that she get off methadone. All went fine until the judge checked to see if she had gotten off methadone--which she had not [and why should she have to? The judge is not a doctor!], and he ordered that she detox from 70 mg/day in 10 days. She could not do it, though she tried, and then she used heroin which gave her a positive urine (which is why she is in jail--a violation of probation because she did not get off methadone when ordered and then gave a positive urine for heroin).
Your tax dollars are paying for this patient's incarceration.

This patient was not detoxed and had to withdraw without any medical assistance. The entire incident is just plain cruel.

NAMA will continue fighting for this case. Lynn has asked to have newsletters sent to her and that she will distribute them to other women in the prison. They are all eager for positive information about methadone. We are sending her Methadone Today.

If anyone would like to drop Lynn a note just to let her know she is not alone, send them to us, and we will forward them to her. P.O. Box 164, Davison, MI 48423-0164 or E-mail:

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If The Other Shoe Fits
by Ken T.

Hello once again to all of the faithful readers of Methadone Today!! We certainly appreciate and need more support through your time, subscriptions and donations to keep the newsletter afloat and in print. Many thanks to those of you have already helped defray the costs of publishing our/your newsletter.

Several months ago, I wrote a spirited, if not, scathing article concerning rude and impolite staff of methadone clinics. After much soul searching and dealing with guilty feelings that invaded my every thought of the methadone clinic, I am finally able to touch upon the flip side of this matter--impolite and impatient methadone patients. Those types of patients and staff members alike tend to fall into the minority of individuals working within or attending the methadone clinic to receive help for their addiction.

Apologies have been made to anyone who was offended by my previous article. Again, my article was not meant for, nor directed at, any one person in particular.

Feelings were hurt, and fingers were pointed, but I cannot stress enough that my article, "If The Shoe Fits", was not written for or about any one certain staff member. Once again, to anyone whom I may have offended, hurt or made angry with my article, I am sorry. Please do not harbor a dislike or continue to be bitter.

Each of our lives may be different, but they are absolutely way too short to expend energy or time disliking one another. We are all brothers and sisters, no matter our race, color or creed, co-existing on our same, beautiful planet. If we each work together, helping one another and those less fortunate, this lifetime will be so much more enjoyable and pleasant.

As a patient of a methadone clinic, it is to our advantage to realize and understand that our clinics' staff must learn to deal with a diverse variety of personalities and lifestyles on a daily basis. All must try to separate fact from fiction, imagination from reality, and truth from lies. This is not a skill that is learned at a seminar or through any type of schooling. It is learned from time, and only time. Try to remember this the next time you must wait in line to dose or while waiting to see your counselor. Deal with it by understanding and patience. A friendly face makes everyone feel a bit better.

As a nurse or patient, counselor or administrator, we have, like it or not, come together within the methadone clinics of the world as if the Fates themselves have touched each of our lives and have brought us together for the same basic reason. Teacher and pupil? Maybe! And not necessarily staff teaching patient. We all learn from each other. Somehow, in an unknown way, for yet an unknown purpose, fate has caused us to cross paths.

In a world where death is the only ultimate certainty, and self-preservation is the first law of nature, is it really worth the effort to hold a grudge or stay bitter? Somewhere within the far reaches of each of our minds exists the same thoughts of prosperity, love, peace, a better way or just a settling of our souls. Are we really that much different? Such are the hopes and dreams of all as members of the human race. These thoughts are not impossible if we just try to be a little more understanding of each other.

Each and every one of us experiences a bad day, a bad week or battles with a sad, lingering memory. Be understanding and thoughtful of one another because with each passing moment, we lose precious time off our lives. Is it really worth it to stay mad at someone? Try to treat another as you, yourself, want to be treated. An old line? Yes--but it does work!!

Try to remember a bad day that you may have had or how a bad experience was finally dealt with by being positive. Maybe the smile or a hello from a stranger lifted your spirits when you were feeling down? Or, how you may feel lost at times in a sad, strange world and how a word of encouragement made you feel so much better.

If any one of us, patient or staff, are left wondering just how could the years have passed so quickly, remember to say, "hello" to someone who looks depressed, open a door for someone who may need it, or just offer a friendly smile to a stranger. I think most of us would be pleasantly surprised at just how wonderful it makes you feel inside.

Maybe then we may not have to face the unknown future feeling alone, and just maybe we may finally learn the true meaning of peace, contentment and happiness. Only time can heal the hurt of the heart and soul, but something as simple as a smile can begin this healing.

Take time to Think; it is the source of Power. Take the time to be Friendly; it is the road to Happiness. Take time to Dream; it is the road to Greater Vision. Take time to Give; the day and our lives are too short to be selfish. But most importantly, take the time to Love And Be Loved, for love is a privilege of the Blessed. Peace!

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NAMA's Methadone Awareness Test

Methadone was named for Adolf Hitler. True or False?

False. This is a very commonly believed myth. While it is true that methadone was first synthesized by German pharmacologists during WWII, its properties were not discovered until after the war. "Dolophine", the original trade name for methadone hydrochloride, was not derived from the name "Adolf", but from the Latin "dolor" (pain) and "fin" (end).

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Briefly Speaking

1736 - The Gin Act (England) is enacted with the avowed object of making spirits "come so dear to the consumer that the poor will not be able to launch into excessive use of them." This effort results in general lawbreaking and fails to halt the steady rise in the consumption of even legally-produced and sold liquor (Catlin, Liquor Control, p. 15).

1838-42 - The First Opium War. The British force upon China the trade in opium, a trade the Chinese had declared illegal. . . (Montagu, p. 67).

1882 - The Personal Liberty League of the U.S. is founded to oppose the increasing momentum of movements for compulsory abstinence from alcohol (Catlin, Liquor Control, p. 114).

Have we learned anything from history? Or is there too much money involved in the illegal drug trade for the drug warriors to change our policies now?

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Please Note

Parkview Picnic Sponsored by Roseville (Rain or Shine): Saturday, July 12, 1997; 7:00 a.m. - 5:00 p.m. at Kennedy Park--Schroeder & 9 Mile. For all Parkview patients, staff and their families. Bring a dish if you wish! *Donations of $5.00 will be appreciated.

Katharine Bolton's fine newsletter, Methadone Awareness is again available and can be ordered from Katharine by writing to her at 617 Pine Street, #2, Philadelphia, PA 19106; E-mail - A yearly subscription is $10 to help offset postage and printing costs.

CORRECTION - Last month's Methadone Today, June 1997, p. 2, column 1, last paragraph, first line, should read: "For $10 per year," instead of what was printed, "For $10 per month" (which is incorrect). Sorry - The Editor

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