|
Your letter
head
Give this
to patients to have with them when
they
see a physician or dentist
Dear
Doctor:
The
bearer of this letter is a patient in a methadone maintenance treatment
program.
Methadone patients frequently need
treatment for
other medical, surgical, and dental conditions.
At times the health professional is not familiar with addictive disease and
the various forms of
treatment,
including maintenance pharmacotherapy using methadone or
LAAM. The
reaction to
being informed about
the addictive
disease/methadone treatment often includes fear, anger,
prejudice,
disgust, and other negative subjective responses, none of which contribute
to the
objective delivery
of quality health care. Many patients are very reluctant to provide
information
to the other health
professional about their addiction and treatment with methadone or LAAM because of
previous unpleasant experiences. The most common reaction is based on fear
and
disgust which is
inversely proportional to the professional's level of familiarity with
addiction
medicine and
patients with addictive diseases.
The purpose of this brief letter is to touch on the
most common
problems encountered and to offer any assistance I
might be able
to provide.
It is widely
accepted that addictions are diseases and that their treatment is a
legitimate part of
medical
practice. Addictive disease can be characterized as a chronic, relapsing,
progressive,
probably incurable,
and
often fatal (if untreated) disorder. The principle diagnostic features are
obsession,
compulsion, and continued use
despite
adverse consequences
(loss of control).
Methadone
has been used in the treatment of opioid dependence for over 30 years. It
has been
found to be both
effective and safe in long term administration. An adequate individualized
daily
dose of methadone
eliminates drug craving, prevents the onset of withdrawal, blocks (through
opiate
cross-tolerance) the effects typical of other opiates, such as heroin or
morphine.
Efficacy of treatment is based on elimination of or reductions in
illicit/inappropriate drug use, elimination
or marked
reduction in illegal activities, improved employment, pro-social behavior
and
improved general
health.
Such treatment has been shown to be effective in reduction of the
spread of HIV
and other infections. Dramatic reductions in
mortality rates are
seen in
methadone maintained
patients in comparison to untreated addicted populations.
The
methadone maintained patient develops complete tolerance to the
analgesic, sedative,
and euphoric
effects
of
the maintenance dose of methadone. Tolerance does not develop to
the effects
of reducing drug hunger and
preventing
the onset of withdrawal syndrome.
Methadone
has a half-life in excess of 24 hours which makes single daily dosing
possible.
Methadone has a
relatively flat blood plasma level curve that will prevent the onset of
abstinence
syndrome for over 24
hours without causing any sedation, euphoria or impairment of
function.
Along with discrimination, and related to the same stigma, the failure to
provide adequate
treatment of pain
methadone maintained patients is a common and very serious problem..
Since
the patient is fully tolerant to the maintenance dose of methadone No
analgesia is
realized from the
regular daily dose of methadone.
Relief of pain depends on maintaining
the
established tolerance level with methadone and then providing additional
analgesia. Studies
have shown that
exposure to adequate doses of narcotics for the relief of acute severe pain
does
not compromise
treatment of the addiction.
Non-narcotic
analgesics should be used when pain is not severe. In the event of more
severe
pain the use of
opioid agonist drugs is quite appropriate. The dose of opioid agonist drugs,
such
as morphine, is
usually increased to compensate for the opioid cross tolerance established
by the
methadone. Also, the duration of analgesia may be less than usual. Doses
must be individually
titrated to ensure adequate analgesia. Best results are obtained with a
scheduled
dosing as opposed to
PRN. Morphine may be required q 2-3 hours at whatever dose that
provides
relief.
There
is no justification for subjecting a maintenance patient to unnecessary pain
and suffering
because of their
disease or its treatment. Adequate treatment of pain will ensure a more
pleasant
hospital stay as well as enhance healing and recuperation.
Opioid
partial agonist and agonist/antagonist drugs such as Buprenex, Talwin,
Stadol,
and
Nubaine
should never be used in the methadone tolerant individual.
Severe opiate
withdrawal
syndrome can be precipitated by drugs of this type.
Both
propoxyphene and meperidine are known to produce CNS excitatory metabolites.
Due to
the cross tolerance
the higher doses required to achieve analgesia can increase the risk of
seizures. For
this reason propoxyphene and meperidine should be avoided in the maintenance
patient.
The
administration of opioid agonist drugs should be closely supervised in terms
of quantities
and duration.
Prescribing for self-administration by the patient should be carefully
monitored. If it
is necessary to prescribe for self administration, caution should be
exercised in the amounts
prescribed
and refills carefully supervised.
Similar precautions are indicated in the prescribing of sedative/hypnotic
and CNS stimulant
drugs. The abuse
potential of ALL benzodiazepines is quite high.
At times the attending physician is tempted to treat
the opioid dependence itself. This is usually
attempted by
tapering the methadone dose to zero. If successful, the graded reduction may
result in a
reduction or elimination of the physical dependence but has no effect on the
disease
itself. Even after
the methadone is discontinued significant signs and symptoms of abstinence
may persist
for several weeks and even months. The relapse rate associated with
detoxification
alone approaches
100%. A relapse to street/illicit drugs increases risk of overdose,
hepatitis,
AIDS, and a host of
other biomedical, psycho-social, legal, and other complications.
Under some circumstances some form of intervention can be accomplished
during a hospital
stay for other
conditions when desired by the patient and in consultation with the
methadone
program physician.
Such a process should involve experienced addiction professionals with a
strong
emphasis on continuity of care upon discharge.
If you have
any questions or concerns about our mutual patient in relation to methadone
or drug
dependency please
call me. I would be delighted to hear from you.
Sincerely,
Your name
and special instructions
|
