Metha-Don't

A consideration of some of the most significant drawbacks of Methadone Maintenance Treatment (MMT), informed as always by extensive, unfortunate personal experience. 

Several take-home doses of methadone - the infamous liquid handcuffs. 

For the young Jedis among you: In the context of this discussion, Medication Assisted Treatment (MAT) for opioid addiction involves switching a patient from whatever opioid agent they are addicted to (oxycodone, hydrocodone, heroin, fentanyl, et al) to another opioid, typically buprenorphine or methadone, that is taken once or twice daily. Although these latter medications activate the same receptors as other opioids and produce many of the same effects in the brain and body, buprenorphine and methadone have properties, including long half-lives and - in the case of buprenorphine - a lesser stimulation of the opioid receptors, which allow physical and psychological stabilization that is not possible for addicted patients who are taking other opioids. 

One of the concrete - pun pun pun; get it, it’s a pun - advancements in addiction treatment that has been realized in New York State and other areas with progressive policies during my lifetime has been a dramatic reduction in the wait time for doctors who prescribe buprenorphine and methadone. When I was first searching for a buprenorphine / Suboxone prescriber in my early twenties, even with Cadillac insurance coverage in a state with a relatively high number of clinicians with the special certification necessary to provide these drugs, you were looking at a minimum of a month for a slot to open up. Wait times for methadone programs could be nine months to a year or more. Thankfully, the overly restrictive requirements for such programs and providers have been eased somewhat, and the overall number of trained providers has increased with demand. 

When I enrolled in a methadone program two years ago after a years-long relapse into prescription opioid and benzo addiction, I was set up with state insurance (Medicaid) and enrolled in the program in a shockingly efficient three days. This reduction in wait times is a huge achievement; needless to say, people who were ready and willing to engage in treatment died, lost limbs, damaged heart valves and livers, and were arrested and incarcerated during those weeks and months of waiting. Let’s take a moment to remember that, in the face of a seemingly ineluctable epidemic that has caused such despair, we are making progress, and we do recover (with or without MAT). 

Unfortunately, not a single staff member at the clinic questioned whether methadone was a suitable option for me; the presumption from the time that I made my first appointment at the clinic, which was by self-referral, was that I was a suitable candidate. To be succinct for a change, I ended up strongly wishing that I had instead pursued a monthly buprenorphine injection, an option which wasn't on my radar because it hadn’t been available during my last stint in treatment years earlier.

Without further ado, these are a few of the key downsides of Methadone Maintenance Treatment (MMT), which is one form of MAT for opioid addiction.

1. In the beginning, you are required to show up at the clinic six or seven days a week to dose each morning, typically between 5:30 a.m. and 10 or 11 a.m. You will also be required to submit to random drug testing, which can increase the hour or so (with transportation time) that you’re committing to this treatment every single day. 

Although the staff at the clinic that I go to are mostly kind, competent people, there is a certain spiritual degradation inherent in being observed at a dosing window every morning as the very first element of my day. To be succinct (again!), the regulations that require this for MMT are draconian and constitute blatant discrimination against drug addicts compared to other patient populations; they were formulated during a different epoch, when drug addiction was frightfully stigmatized, and they should have been reformed or repealed years ago. 

In other countries, including the UK, methadone can be picked up at a pharmacy weekly, bimonthly, or monthly; this improves access, retention, and patient outcomes. In the United States, methadone clinics have powerful lobbies that actively oppose changes to the current system. On an optimistic note, however, I am aware of several companies that have designed new systems, including tamper-resistant labels and “portable clinics” that patients can take home as well as apps that video-record patients taking each day’s dose, which reduce the required in-person appointments to once or twice a month. Addiction is the most heavily regulated area of medicine that I am aware of, and this kind of pseudo-penal monitoring still constitutes discriminatory treatment of addicted people as a patient population, but progress is progress, and we’ve got to get to where we’re going from where we’re starting, not from where the UK or the Netherlands is. 

So, point number one is to think long and hard about how dosing will fit within your daily schedule, especially given constraints around transportation, weather, work, family responsibilities, and other medical conditions and treatments. In my experience, patients tend to underestimate the onerousness of in-person daily dosing. The frank truth is that take-home doses are earned slowly and that the vast majority of patients never achieve the 30 days of take-home doses that are technically possible under the most “generous” programs. (The program that I am enrolled in, for example, will limit take-home doses to two per week unless you are working 20 or more hours; for elderly and disabled patients, some of whom are receiving what is effectively end-of-life care, this is cruel, illogical, and decreases patient retention and motivation).

2. Methadone is a full-agonist opioid with a highly variable half-life, and if your body eliminates it faster than is compatible with once daily dosing, you are going to end up spending a significant portion of each day in withdrawal. The first part of this - that methadone is a full-agonist - simply means that its effects on the brain and body increase in proportion to dose / blood concentration. This is a good thing in some cases, because partial agonist opioids like buprenorphine have a ceiling effect, meaning that patients dependent on high doses of full agonists and / or especially potent drugs like fentanyl may not have their withdrawal symptoms adequately ameliorated by buprenorphine (in fact, this situation can lead to a nightmare known as precipitated withdrawal when buprenorphine is given to someone dependent on a full-agonist whose opioid tolerance is too high, but that is beyond the scope of this discussion).

The important point is that this isn’t such a big deal if your body eliminates methadone on the half-life of 12 to 24 hours that is suggested as average by some sources; you’re still going to have somewhere between 30% and 50% of the previous day's dose when you dose 24 hours later, and that should be enough to ward off severe withdrawal reactions. 

Methadone has a long average half-life, true, but it also has one of the most variable half-lives of any opioid (I have seen half-lives as short as five hours cited in the literature). What this means is that you are going to have effectively none of the drug left in your blood by the time that you dose 24 hours later, and depending on when during the day it wears off, you are going to spend most of the evening and night in significant discomfort. 

Methadone clinics are aware of this problem to some extent - though many clinicians at my program had no idea that it existed and cited the 24-hour half-life as though it were Biblical truth. For this reason, some programs offer twice-daily dosing to a very small number of patients, but this requires peak-trough blood testing and often additional paperwork filed with regulatory authorities. 

I went through this because I take a full-replacement dosage of synthetic thyroid hormone (levothyroxine) for a non-addiction-related, autoimmune thyroid condition. I was burning off the methadone so quickly that I was spending every night fully awake, sweaty, with dilated pupils, bone and muscle aches, and urges to use. I could come to terms with these negative side effects, since the net effect of methadone in my life was still a positive. What I couldn’t contend with in the long term, however, was the massive feeling of physical and mental relief that I experienced each morning after dosing. (Anyone who has been addicted to opioids knows that the obsession with one’s withdrawal symptoms, and the feeling of relief after dosing, is a powerful driver of the addiction). The point of MAT is that it is supposed to smooth or stop the wild ups and downs of blood levels of medications in active addiction, and if it doesn’t do this, you will essentially just experience addiction to methadone. 

The staff at my clinic upped my dosage to a massive 190 mg of methadone per day before even considering peak / trough testing (and this was for a patient on a metabolism-altering drug known to interfere with methadone maintenance). 

For this reason, as long as there is no reason that your body cannot tolerate buprenorphine, if your tolerance is low enough to be maintained on buprenorphine rather than methadone, that option should always be taken (in my opinion). The ceiling effect of buprenorphine means that it is much easier to maintain a stable level of opioid receptor stimulation, which makes MAT effective. 

*How do you know if your tolerance is above or below the ceiling stimulation provided by buprenorphine (which I have seen cited as equivalent to 25 to 40 mg of methadone per day)? Clinicians have charts, which you can also find online, allowing them to make rough equivalencies between prescription opioids; good clinicians also have an idea of how people using various amounts of illicit opioids in their area react to buprenorphine and methadone at different dosages. Sometimes, unfortunately, the only way to know for sure is to experiment on yourself (under clinical supervision!).

3. To add to what I have said in point (2), the biggest argument for not going on MMT is that buprenorphine is so far superior by so many metrics. You are more likely to be effectively stabilized; you will quickly be allowed at-home dosing for weeks or months at a time, or you can take an injection that will last for several weeks; you will end up on a lower effective dose of opioids than on methadone, which must be increased over time because full agonists cause tolerance buildup for all patients to some degree. 

4. Even if methadone works for you, it can take forever to reach an effective maintenance dose. I went up as fast as my clinic allowed in the beginning, starting at 20 mg per day and increasing from there first every day, then every three to five days. It took me a good six months before I was feeling significant relief for 12 hours after dosing. 

During this same time, if I had been on buprenorphine, yes, I would have been experiencing withdrawal symptoms equivalent to the difference in opioid receptor stimulation between the opioid that I was dependent on before starting treatment and the ceiling effect of buprenorphine. However, at the end of this discomfort, I would have actually become less dependent on opioids and stabilized with respect to blood levels if I had gone on buprenorphine, two things that were not true for me on methadone. 

The Infamous Opioid Constipation Visage. You all know that your boy is too classy to make this one a separate point, but – perhaps because it is taken orally – methadone caused opioid constipation far beyond anything that I had experienced even on high doses of oxy and heroin and fentanyl. Suffice it to say that taking a methadone s*it was the only time in a wildly painful life that I have actually lost consciousness due to pain; it felt like someone was jabbing a knife into my rectum. Like the little foxhole theist that I am, it also made me pray – like, I am not kidding, really pray, offer to dedicate my life to God – for the first time in several years. There are meds that help with this significantly, I can happily say. The constipation part, at least.

5. Participation in MMT will greatly restrict your ability to take other medications for any reason. At my clinic, it is difficult to get prescriptions for things like gabapentin, and it is nigh on impossible to get benzos (even if, as in my case, you have taken them for most of your adult life). The clinicians are worried about increased respiratory depression from using these downers in combination with methadone; this is a valid clinical concern, but if someone is still using outside of the clinic because they aren’t getting adequate relief from methadone alone, the risk of them dying is exponentially higher from that than it is from any combination of prescribed, managed meds. For this reason, countries with more progressive MMT protocols have achieved much higher retention and success metrics by prescribing patients break-through opioids, benzos, and other drugs. Things like ADHD medications are also an issue, as the stimulant meds can increase the rate at which methadone is cleared from your body. 

Forget about alcohol, which most clinics will not allow you to drink at all even if you have never had a problem with it, and in many cases non-medical THC, as well (at my clinic, several patients with medical weed cards were reputedly refused take-homes because they had been given cannabis use disorder diagnoses at some point in their addiction treatment [this can just mean that an intaking clinician noted that you used weed without a prescription at some point in the distant past]). 

*Please be aware that being treated surgically or under hospitalization for other issues on methadone can be a harrowing experience. Clinicians’ level of knowledge has increased in the past 10 to 15 years, but many still subscribe to frighteningly ill-informed beliefs (for example, that patients stable on MMT get pain relief from their daily dose; not true). 

6. You must always be available for a recall, during which you bring in your take-homes so that the clinic staff can verify that you’re taking them as directed. If you miss the call to notify you of this for some reason or are forced to travel suddenly without having time to make appropriate arrangements with your clinic, the best possible outcome is that you will lose your take-home doses. 

It is possible to travel while on MMT, and clinics may give you special take-homes for a trip if they deem it important enough and you stable enough (however, this involves a significant discretionary component). 

*One of the most ridiculous things that I heard of a patient at my clinic losing take-homes for was having a “damaged” label on one of her bottles, which must be returned, which had a small scratch on it; this is the kind of ridiculousness that comes about from clinic politics and power plays, discussed below. She was someone who had been stable in the program for a long time and who I think was very likely telling the truth about not having tampered with the label intentionally. 

**Another thing that I experienced personally was a false-positive drug test. I looked into things further and learned that my clinic was using Quest’s initial, presumptive, antibody-based drug test as a final (confirmed) result because my insurance would not cover the confirmatory GCMS testing that even Quest’s paperwork stated was required; because of this, when I brought the issue to their attention, they had to switch drug test providers. Had I not successfully challenged this, I would have lost my take-homes due to a false positive. I intend to write a second post at some point on methadone clinic policies that I have successfully challenged at the hospital level, as well as what methadone patients can do to achieve change at the state and federal levels.

Needless to say, it makes it very difficult to “trust in the process” when you see the low level of education of many counselors at these clinics and then learn that they are revoking take-homes based on an easily corrected misconstruction of drug testing results. 

7. Clinic politics and a punitive mentality: Methadone clinics have a distinctly correctional vibe. Many of the clinicians at my clinic, which I consider to be quite good in terms of the grand scope of services currently offered in the U.S., have more of the mentality of correctional officers than addiction counselors. Their presumption often seems to be that their patients are lying, and a few of them seem to enjoy the power they wield to a grotesque extent and / or nurse unhealthy beef with select patients. Anyone who has been in an MMT clinic knows about the importance of staying on the staff’s good side and the drama that occurs when someone falls from grace. 

There is so much more that I want to say on this topic, but I am conscious that I’m pushing against the upper limits of readable length for most of my audience. Perhaps I’ll hold a podcast with other patients and / or MAT clinicians at some point, and then come up with organized notes to use in individual and group advocacy. For the time being, let me end by saying that methadone saves lives, and that it is vastly preferable to be alive and dealing with all of the above downsides of MMT then dead of an overdose or other complications of addiction. However, the availability of buprenorphine, as well as the fact that many patients are not able to successfully stabilize on methadone, mean that all available options should be carefully considered. 

For those of you who don’t know, my undergraduate degree is in physiology, and I completed two semesters at a U.S. medical school. I tried to keep the jargon in this piece moderate, if not minimal, and you’re always welcome to comment with a request for clarification.