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Addict In The Family
by Dr. Andrew Byrne
WHEN TO BEGIN REDUCTIONS
HOW TO REDUCE DOSES
The incentive to come off methadone treatment may come from many quarters. One common reason is the rigour of the treatment itself. Dispensary hours may be very limited, such as from 9 to 11am. Patients may have to attend every day, even on weekends when transport is difficult. The methadone dose levels may be inadequate and 'penalties' may be incurred when days are missed. Some clinics may deny patients medication if they are unable to pass a urine specimen on the spot.
These difficulties can result in frustration and rejection of the treatment by the patient. It is important to realise that patients who withdraw from methadone for these reasons alone have a very high relapse rate, perhaps as high as 90%. In other cases, there may be other more valid reasons behind the initial catalyst. Such factors may include an intention to have a baby, a strong desire for abstinence or a need to travel to areas where methadone is not available.
Another consideration sometimes given for withdrawal from methadone is religious. This rationale treats methadone as 'just another mind altering drug' rather than as a prescribed medicine. Drugs and alcohol are an entrenched part of many organised religions. Devout Jews and Christians celebrate the Sabbath by drinking wine. There was alcohol at 'the last supper' and one of the miracles Jesus is said to have performed was the converting of water into wine, further sanctifying the beverage. Other religious groups use cannabis, peyote cactus or other drugs for ceremonial or spiritual purposes. Hence a religious edict against drug or alcohol use is upheld by some but completely contrary to other religious observances. In either case, it should not influence the correct treatment of an unstable drug user in the short term.
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This is a term which means different things to different people. Some psychologists and counselors use the term to refer to other active parties in a drug user's sphere. This should not be confused with dual dependency which is when a person is addicted to two drugs simultaneously, especially alcohol, tranquilizers or narcotics. In some cases one drug is used to excess because of the lack of the 'primary' drug of addiction. The 'secondary' drug may also be more harmful, and the person therefore at greater risk. This may occur in patients on inadequate doses of methadone and who are still abusing other drugs, including non-opiates. On the other hand, 'co-dependency' is an interesting concept but a difficult and ill-defined term. It might be best avoided except by professionals.
Before commencing methadone reductions, the patient should have ceased all co-dependent drug use, including heroin, for at least three months. This should be in addition to other signs of stability, such as employment, an absence of acute medical illness and a mental resolve to withdraw from opiates.
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Given that the patient has been stable on a regular methadone dose for at least four weeks and is suitably motivated, then a reduction of approximately 10% of the daily dose may be undertaken as a trial. This should always be organised a few days ahead, as it is never an urgent decision. This allows a change of mind and delayed reductions if the patient lacks confidence. Pressure from others to reduce doses is destabilising and must be resisted.
As long as the patient tolerates the new dose, then a further 10% reduction may be taken after a further two weeks. The steady state blood level of methadone is not achieved until five to seven days after a dose change, so it is inappropriate to alter doses within the one week. A two week period therefore allows this second week to see if the lower level is tolerated.
A simplistic theory stated by many people goes: 'if you reduce the dose steadily over a certain period, the addict should be able to cut the medicine out altogether and their addiction will be conquered'. Even a number of addicts hold to this attractive but erroneous belief. It has been tried a thousand times! If it were true, then addicts would all be able to cure themselves, and there would be no problem, and no books like this! It simply does not work, and denies the very nature of compulsive behaviour. It would be as useful as saying to an overweight person to 'if you eat a bit less every day you will cure your obesity'. Of course, it is true, but to recite it is patronising, unhelpful and shows an ignorance of the human condition.
But gradual reductions do work in certain instances. Usually over quite extended periods, they should be initiated by the patient themselves in a climate of stability and control. Generally the dose reduction increments are 10mg above 80mg and 5mg steps at lower levels. Some patients request 2½mg increments below 20mg. Everyone agrees that the most difficult period of reductions is the last 20mg. This may take even longer than the time taken to reduce from 80mg to 20mg. And we now know that the longer it takes, the more likely it is to result in long term abstinence.
The temptation to use other medications during methadone reductions may be strong. Sleep is often a problem, but tranquillizers and sedatives are not appropriate. Headaches and other pain syndromes may occur. Aspirin or paracetamol (US: acetominophen) may help temporary pains, but it is illogical to use the stronger narcotic pain killers. Codeine in small doses such as 8mg will have little effect, while larger doses will give a greater narcotic 'habit', placing abstinence at an even greater distance. Such drugs will also confuse the interpretation of urine testing if this is part of the patient's treatment regimen.
There are other ways of relieving these problems without resorting to drugs. Massage, exercise, herbal remedies, vitamins and diet can all be of benefit in some cases. Alternative therapies such as acupuncture and hypnosis may also have a role in some patients.
The 'last dose' may be a planned affair, but more often the patient on quite low doses, such as 2.5-10mg, will just decide to cease attending the dispensary.
There have been reports of addicted patients who were given a narcotic antagonist such as naloxone or naltrexone experimentally while under a prolonged anaesthetic. This is an extreme measure to consider, and shows the length to which some people will go to overcome their addiction. How long the abstinence lasts and what incidence of ill-effects ensues may be determined by future formal studies.
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If the patient becomes too ill during reductions or after the last dose, then it may become necessary to review the prescription. The symptoms of such 'illness' can mimic many other medical conditions. If illicit heroin is used on more than one occasion then it is nearly always necessary to reinstitute full methadone maintenance treatment.
Such a course should not be seen as admitting defeat or failure. It is merely a demonstration that the addict's body is still conditioned to narcotics and is not yet ready for abstinence. This very exercise may be important for some addicts and their doctors in justifying continued long-term treatment. Where the person is stable and in control, it may be possible to keep the dose in the low range, but where there are signs of instability or medical illness, the dose usually needs to be restored to the previous maintenance levels.
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|Dr. Andrew J. Byrne received the prestigious Marie Award at the 2006 national conference of the American Association for the Treatment of Opioid Dependence.|
|For more information about pain management and opiate pain medication, check out ManagingChronicPain.org.|