The "Dear Doctor" Letter
Dr. Shinderman's (CAP's) letter for use by his Methadone Maintenance Treatment Program to educate their physicians regarding the treatment of pain, drug inter-actions, anti-viral therapy and organ transplants as they are related to methadone maintenance. Methadone Maintenance Treatment Practitioners are encouraged to adapt CAP's letter to their needs.
Please feel to
adapt letter to
Opioid Treatment Program Name
CITY, STATE · ZIP ·
Date: (July 3, 2005) Reference To: (Patient's Name)
This is a general letter in reference to our mutual patient(s) maintained on methadone in our Opioid Agonist Treatment Program (OTP).
Methadone maintenance has been used in the treatment of opioid dependence since the 1960's. The methadone-maintained patient develops complete tolerance to the analgesic, sedative and euphoric effects of methadone. The stabilized patient also avoids the opioid abstinence (withdrawal) syndrome and craving for opiates. Sedation in the stabilized methadone maintained patient is almost always attributable to concurrent medical conditions or to methadone’s interaction with other drugs.
The best policy is to coordinate your medical treatment of the patient with his/her Opiate Treatment Program. Confidentiality regulations that apply to substance abuse treatment are unique and restrictive; a signed release of information is required before our staff can acknowledge a person is a patient and discuss specific issues about his/her treatment. However, even without a release of information, our medical personnel can direct you to appropriate resources or answer questions regarding major drug-drug interactions, cardiac considerations, safety of breastfeeding, methadone and pregnancy issues, et cetera.
Pain management in the methadone maintained patient is frequently misunderstood. The stabilized patient may experience some analgesia for 2-6 hours, from their dose, but it is usually insignificant. Pain relief requires prescription of additional medication appropriate for the nature of the pain, including long and short acting opioids. Methadone can be an excellent analgesic. To be effective for pain, however, methadone must be administered in divided doses, 2 to 4 times a day, and in a total dose that exceeds the patient’s maintenance dose. A single methadone dose exerts analgesic effects lasting 4 to 6 hours, in most instances, with some variation.
For the medical provider treating a methadone maintained patient for pain, coordinating and documenting treatment with the Opiate Ttratment Program is best from both medical and legal perspectives. It is essential to obtain a release of information from the patient, and contact his or her clinic, to establish coordi-nation of treatment with the Medical Director, or his designee if you treat a methadone maintained patient for pain, with opioids. While some patients can be managed no differently than patients without addiction history who take metha-done, others, must be monitored closely. Personnel at the clinic can provide information on methadone’s significant reactions with other medications, induction protocol, maintenance dosing, and metabolic differences from other opiates or direct you where to find it, on the internet. (See below) We suggest that you ask for a letter from us, with our recommendations, or make a note of our verbal interactions, in addition to using a standard pain contract and documenting the source of pain and the history of its treatment.
When considering analgesia, some methadone-maintained patients can be managed the same as those without an addiction history. Others must be monitored closely, regarding medications associated with neurobiological reward mechanisms, such as opioids, stimulants, or benzodiazepines. If opioid medication is required, the required dose will be at least 10% to 50% greater than for non-opioid tolerant individuals. This is due not only to high opioid tolerance but also to the reduced pain thresholds of methadone- maintained patients. Also, administration of opioid analgesics may need to be more frequent than usual (q 3-4 Hr versus q 4-6 Hr for non opioid tolerant individuals).
If it is necessary to prescribe opioids for self-administration, long-acting drugs are preferred for chronic pain treatment, including methadone. When short-acting opioids are indicated, a week's supply or less of medication with a small number of prescription refills, if any, serve the needs of most methadone maintained patients. Talwin, Stadol, Nubain, and buprenorphine can precipitate severe opioid withdrawal (abstinence syndrome). Many patients experience discomfort with tramadol. Darvon (propoxyphene) and Demerol (meperidine), in higher doses, cause seizures in methadone maintained patients. Naltrexone and naloxone precipitate severe withdrawal.
Some anticonvulsants, tricyclic antidepressants, SSRIs, etc., can be used adjunctively for the treatment of pain. However, NSAIDs, (ibuprofen, rofecoxib, etc.) might promote cirrhosis in patients with Hepatitis C, and should be used only when HCV is known to be absent. Dilantin, phenobarbital, and Tegretol and rifampin should be avoided because they strongly induce CYP 3A4 metabolism of methadone. If necessary, use of these drugs without causing undue suffering can be accomplished if the methadone dose is increased, even doubled, to balance the rapidly increased metabolism. Caution must then be used when such agents are discontinued to avoid overdose or intoxication when such metabolism rapidly diminishes. Valproic acid, divalproex, and gabapentin are useful alternatives for anticonvulsants. Ethambutol may substitute for rifampin, when not contrindicated by hepatitis.
Methadone maintenance treatment is NOT a contraindication for the appropriate use of psychotropic medication in the 60% or more of patients with addictive disorders having Axis I psychiatric comorbidity. While most psychotropic medications have interactions with methadone, some of which can be conse-quential, and others have the potential for abuse, most can be used with proper monitoring and awareness. Making individual determinations in each patient regarding the use of benzodiazepines or stimulants is preferable to precluding their use entirely in methadone-maintained patients. Our OTP clinical staff can help you assess risks of diversion, drug abuse, or medication interactions. For problematic patients our clinic might assist with monitoring or administration of medications, if appropriate.
Regarding patients whose stabilization of significant psychiatric pathology or chronic pain is attributable to the effects of methadone, discontinuation of methadone maintenance treatment is relatively contraindicated. Substantial evidence exists that methadone itself may engender potent psychotropic benefits as an antidepressant, antipsychotic, and stabilizer of labile affective states. Finally, there are few contraindications for stabilized methadone-maintained patients regarding treatment of hepatic disease, HIV-related illness, or organ transplantation.
Useful information about methadone’s significant interactions with other medica-tions and its metabolic differences from other opiates (such as its metabolism by CYP450 2D6 enzymes, propensity for accumulation, slow onset of action, etc) is readily available on the Internet or upon request from our clinic. Please see the following resources from the www.atforum.com web site concerning methadone-drug interactions, cardiac considerations, and dosing and safety issues:
Additional information on methadone metabolism and dose ranges required for effective treatment appear on the “Articles” or “Links” pages at www.capqualitycare.com. If discussion of clinical issues or transfer of records regarding our mutual patient is required, please have the appropriate release of information forms signed and contact us.
Updated: July 3, 2005 Stay-Tuned for more letters similiar to the one above. Please inform us if they are of any help to you. Thank You.