Thomas Payte, M.D.Medical Director September 12, 2003
Bad Patients or Bad Treatment???
To CMG staff at all levels, interested patients & significant others, and anyone interested in quality patient care with favorable treatment outcomes:
Recently I was in communication with a methadone patient and his father involved in a struggle with a methadone program trying to get an adequate individualized dose of methadone. The last report I had suggested that resolution was still pending. Having dealt with many patient-program conflicts, as patient advocate and program physician, I have learned to avoid judgments without input from all perspectives. This correspondence is not an attack on any specific program, rather a condemnation of the practice of denying dose increases despite strong clinical indications that the current dose is not achieving optimal results for the desired period of time. This is a response to a chronic and recurring situation that affords a teaching opportunity. The situation I describe is not at all a rare occurrence.
I like to think that in the 40 years since I treated my first young couple addicted to heroin, that I have learned a few things. Occasionally I learn a valuable lesson that is not found in journals, policies, procedures, or guidelines. The purpose of this letter is to share that experience and it’s simple lesson.
In 1985 we were in the midst of a low-dose hysteria that was running though programs like the Sobig virus is running through computers today. I was not immune to this phenomenon and was trying to lower my maximum doses for take-home to 80 mg. At this point I can’t imagine why I wanted to do that, other than most programs were involved in the same pointless effort without a shred of scientific or clinical evidence to support such bizarre behavior.
In the midst of the frustration of patients complaining and doing poorly, I read an article in one of the addiction journals by Forrest Tennant and colleagues. What they did was to compare a group of really good, well-behaved patients with a group of very poor performers guilty of non-compliance, positive urines, and a host of sins committed against the methadone establishment.
Both groups were on 80 mg methadone daily. The simple test was to measure trough blood levels 24 hours after an observed dose. The average methadone levels for the good guys was over 400 ng/ml, while the bad guys averaged about ¼ of that, with mean trough levels of about 100 ng/ml. In a rare moment of clarity it came to me…Just maybe, the poor performers are not bad patients but are getting bad treatment!
At that point I abandoned the pursuit of the lowest possible dose and adopted individualized adequate dosing, with occasional use of methadone serum levels to detect aberrant metabolism, etc.
Lesson number 2 occurred in the late 80’s when I admitted a patient who had been administratively discharged from another program. He had been considered non-compliant, had positive urines, and was thought to be lacking in motivation, etc. During his admission process I noted that, according to his history, he had never been stable on methadone and his drug use was most likely a form of self-medication’ rather than recreational.
His initial time in our program was dedicated to adjusting his dose to a level that would control craving and prevent withdrawal. This number turned out to be considerably higher than the maximum dose allowed in his former treatment program.
The outcome? Within a few weeks there was a complete turnaround with negative urines and improvement in all domains of the ASI (Addiction Severity Index). He became a model patient and quickly earned full take-home privileges.
Since that time I have had this experience reinforced many times with minor variations.
When faced with a ‘difficult’ patient, the first order of business is to ENSURE THAT THE PATIENT IS RECEIVING AN ADEQUATE INDIVIDUALIZED DOSE
In the simplest of terms an “adequate dose” is defined at that amount of methadone needed to suppress drug craving/hunger and prevent the onset of withdrawal for a time in excess of the dosing interval (usually 24 hours).
While doses in the 80 to 120 mg range are effective for a majority of patients, the actual range of individual adequate doses ranges from as little as 10 mg daily to, in rare cases, up to 500 mg, or more.
It is not my intention to imply that all methadone patient problems are dose related. I do strongly suggest that, as a first step, assurance that the dose is adequate will often correct the problem, and at a minimum, improve the chances of success of other strategies and interventions that will follow.
Before we label a patient as a “bad patient” we need to be certain that the problem is not “bad treatment.”
If you want to know if a patient is on an “adequate dose” simply ask how they are feeling, at various times of day in relation to the methadone dose (4, 12, and 24 hours after dosing). Having asked, then listen. The very first thing that Dr. Marie Nyswander taught was to "always listen to your patient, and you will never go wrong." You have to be able to listen and to ask the questions to get you the answers and information to be able to make decisions to ensure that we are providing quality treatment.
Serum methadone levels will NOT provide this information (adequacy of dose).
I do hope you will consider the contents of this correspondence with an open mind. What is suggested here is really a simple step, which in many cases may be the only step in resolving the problem of a difficult patient.
Don’t be a Low-Dose program, don’t be a High-Dose program, be an Adequate Dose program.
Respectfully submitted in the interest of the best possible treatment for those we serve.
traduzione a cura di Roberto Nardini