Date:
RE: (Patient's Name)
Dear
Doctor:
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 stabilized methadone-maintained patient usually develops complete tolerance to the analgesic, sedative and euphoric effects of methadone. The patient also avoids the opioid abstinence (withdrawal) syndrome and craving for opiates. Sedation in the stabilized methadone maintained patient is almost always attributable, concurrent medical conditions or to methadone’s interaction with other drugs, and far less frequently to the non-compliance with treatment goals and abuse of methadone.
The best policy is to coordinate your medical treatment of the patient with his/her Outpatient Treatment Program (OTP). 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 daily maintenance dose but there is substantial individual variation, and the analgesia is often inadequate even during that brief interval. Substantial pain relief will most often require prescription of additional medication appropriate for the nature of the pain, including long and short acting opioids. Methadone can be an excellent analgesic but to be effective for pain management it must be administered in divided doses, 2 to 4 times a day, and in a total daily dose that exceeds the patient’s usual maintenance dose for the avoidance of craving and opiate withdrawal symptoms.
For the medical provider treating a methadone maintained patient for pain, coordinating and documenting treatment with the OTP 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 in order to establish coordination of treatment with the Medical Director or his designee. While some methadone maintenance patients can be managed similarly to patients without an addiction history, others must be monitored closely. Personnel at the clinic can provide information on methadone’s significant reactions with other medications, induction protocols, maintenance dosing, and metabolic differences from other opiates. This information is available on the internet at the links indicated, below.
We suggest that you ask for a letter from the methadone maintenance clinic 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, as already noted, some methadone-maintained patients can be managed the same as those without an addiction history. Others must be monitored closely when utilizing medications associated with neurobiological reward mechanisms either as a stand alone euphoric affect or use in combination with methadone. There will always be some individuals that will abuse any number of substances, such as stimulants, or benzodiazepines with methadone maintenance therapy. Judgment about a specific patient can be made, more accurately when information is obtained from the OTP personnel.
If opioid medication is required for pain, it is widely recognized that the required dose will be at least 10% to 50% greater than that required for non-opioid tolerant individuals. This is due not only to high opioid tolerance encountered in our population, 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 Ultram (tramadol). Also be aware of the abuse potential of this medication and seizures associated with high doses of tramadol. Darvon (propoxyphene) and Demerol (meperidine), 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, might promote cirrhosis in patients with Hepatitis C, and should be used with caution when HCV is known to be present. Dilantin, phenobarbital, 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. For tuberculosis treatment, ethambutol may substitute for rifampin, when not contraindicated 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 consequential, 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. OTP clinical staff can help you assess risks of diversion, drug abuse, or medication interactions.
Regarding patients whose stabilization of significant psychiatric pathology or chronic pain is attributable or has occurred in the course of methadone maintenance, discontinuation of methadone 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 medications 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:
http://www.atforum.com/SiteRoot/pages/addiction_resources/Drug_Interactions.pdf, http://www.atforum.com/cardiacmmt.shtml and http://www.atforum.com/dosingandsafety.shtml
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.
Sincerely,
(Medical Director)