Past Present and Future: A Selection of Unfinished Business in Methadone Treatment

NAMA at National Methadone Conference – AMTA 2001

Wednesday, October 10th

• Moderator, Howard Lotsof, NAMA Acting Membership Director
• Gary Nessenbaum, Washington Advocates for Methadone Maintenance (President). The Patients’ Perspectives on the Changes in the Methadone Treatment System.
• Carmen Pearman, NAMA Regional Director and The MAG of Indiana (President). Tapering – The Last Ten Milligrams.
• Jo Sotheran, NAMA Board of Directors (Treasurer). Not Available.
• James DePasquale, Long Beach Patient Committee. Organizing Patient Councils. Not Available.
• Joycelyn Woods, NAMA Board of Directors (President). The Changing Role of the Patient Under the New Accreditation System.

This panel will feature presentations by a panel of NAMA representatives, on changes in the methadone system over time, and problems that remain. Topics to be covered include patients’ perspectives on the historical evolution of U.S. methadone treatment, the changing role of the patient under the new regulation system, and several clinical issues including changing dose practices and what clinicians need to know about helping patients taper off methadone.

The Patients’ Perspectives on the Changes
in the Methadone Treatment System

The changes that the methadone treatment system has undergone since it’s beginning is significant. However, it is rarely discussed from the perspective of the patient.

1. Methadone patients are isolated and look to the program for information — but too often the right information that opiate addiction is a medical condition and they are patients and deserve to be treated as such is rarely conveyed.
2. The stigma and misunderstandings have had a significant impact on methadone treatment. During the early years even thought opiate addiction as a medical condition was not understood many of the people working in programs felt they were doing something good for society and they was conveyed to the patient. However as methadone expanded this concept was forgotten. The science that demonstrates that methadone treatment is effective should have replaced the initial feelings that methadone was a good thing, but ignorance has blocked it.
3. Patients come to feel ashamed of the thing that saved their life. They often misdirect their resentment of a controlling program towards the medication.

Post note: I went to the conference with a whole load of bad feelings and anger. I have spent 33 years of having what is called treatment shoved down my throat and was unware there could be so many caring knowledgeable people. Just the fact there was a conference at all of caring pro-methadone people blew me away. Where have they all been hiding? Any way, I came home with a whole bunch of good feelings and hope I left some as well.

Tapering – The Last Ten Milligrams

Very little has been written about tapering off methadone. Brummet et al. (1986) postulate “long-term opiate users face multiple barriers to successful tapering.” It is this author’s intention to show that there are six spheres in which a patient must show satisfactory progress, which should be used as an adjunct to the taper process. The taper process should not be a feared event, but a goal that is obtainable. The “graying” of methadone has indeed motivated many patients to welcome the taper phase upon witnessing the success of their fellow patients and mentors. Teaching the tapering patient methods of endorphin self-stimulation, the importance of a good diet, vitamin supplementation, alternative medicines and behaviors, exercise and psychotherapy during the taper process are all tantamount to success.

Keywords: Methadone maintenance, tapering, spheres of life, psychotherapy, endorphins.

• Patients should have life areas under control before attempting to taper-employment, relationships, health, legal and etc..
• Diet is always important and the use of caffeine and sugar should be reduced and eating plenty of fruit and vegetables increased. The use of a good daily vitamin is also a good idea.
• Exercise is important to stimulate your naturally produced endorphins, serotonin and dopamine so you will feel better during the taper process…exercise that ‘breaks a sweat’.
• Participation in a support group and/or individual counseling during this phase is important so that a patient can receive support during this phase.
• Patient should not be afraid to ask for an increase should they feel uncomfortable-nor feel that they have to taper. It is an individual decision.

Patients wishing to taper from methadone should first be given the information to make an educated decision about tapering and then the support should they decide to. Providers should not make those patients that return to treatment feel like failures. Rather it should be emphasized that relapse is a main feature of opiate addiction and that perhaps at a later time they can try again.

Note: This presentation will be developed into an Education Series. Watch the NAMA website for it.

The Changing Role of the Patient Under the New Accreditation System

As we embark down a new road in hopes of normalizing methadone into medicine providers and patients need to unite and work towards common goals.

The idea that methadone treatment needed changing was begun nearly ten years ago as enlightened providers began to realize that if the industry did not change it was going to destroy itself. Patients began to organize and voice their complaints about methadone. The original regulations were written with the intent that they would be the lowest standard of treatment. It was also assumed that providers would want to provide better treatment. While this may work for most industries including health care it simply does not work when you have:

1. a highly stigmatized and vulnerable patient community,
2. patients that are dependent on the medication (for their survival) and
3. regulations that create a closed system in which a place in treatment is prized.

When your health care consumer will crawl over broken glass to beg for treatment you do not have the typical health care delivery system. Patients are frightened of their programs — even when they are enrolled in what would be considered a good program.

Confidentiality regulations put in place to protect patients has also protected providers that delivered bad treatment. This has been methadone’s “dirty little secret”. Patients were isolated and terrified to do anything that might deny them their medication. This worked not only against patients but also against methadone treatment itself and harms providers that provide quality methadone treatment.

The organization of patients on their behalf along with providers that were sympathetic to patient issues because they wanted to provide quality treatment has galvanized attempts to change methadone treatment. And here we are over ten years later patients, professionals and policy makers undertaking a challenge that is enormous. This cannot be done without everyone working towards common goals and each group – patients, providers and policy makers – has a significant contribution to make to insure that the objectives are accomplished.

Goals for Patients, Providers and Policy Makers

1. Changing clinical practices that are destructive to the industry (i.e. supervised urines, “glass” dose caps, using the medication as a behavioral tool)
2. Legitimizing methadone treatment and educating the medical profession
3. Ending practices that negatively impact treatment (i.e., criminal justice and forcing parolees and probationers to get off methadone, medical care practices such as no pain medication, etc.)
4. Educating the families of patients about the benefits of methadone
5. Changing negative beliefs of patients, professionals, policy makers and the community
6. Including patients in all levels of policy making from the clinic level up to the federal. They bring a level of dedication and determination that others may not possess.

It is time to join together in working toward making methadone treatment a caring and compassionate program and one that we can all be proud of.

Workshop Evaluation