"Dear Doctor" Letter (revised version, February 2004)

The following letter was written by Dr. Marc Shinderman, Medical Director, Center for Addictive Problems, Chicago, Illinois, to be used by methadone patients of his clinic to give to other health care providers. Please feel free to customize and personalize the letter to suit your (patients') needs. We would like to thank Dr. Shinderman for giving us permission to present his letter on our site.


Opioid Treatment Program Name

ADDRESS · CITY, STATE · ZIP · TEL NO · FAX: NO  · EMAIL    

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 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 opioid-drug craving. Sedation in the stabilized methadone maintained patient is usually attributable to the interaction of other drugs or medical conditions.

The best policy is to coordinate your medical treatment of the patient with his/her 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, much less 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, pregnancy issue, or other issues related to methadone-maintained patients.

Pain management in the methadone maintained patient is frequently misunderstood. Patients are fully tolerant to their maintenance dose of methadone and no significant analgesia is realized. Relief of pain depends upon prescription of additional medication that is appropriate for the nature of the pain, including long and short acting opioids. Methadone can be an excellent analgesic; however, to be effective for this purpose, it 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 8 hours.

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. Getting written recommendations from the OTP, making written notes of verbal recommendations, using a standard pain-treatment contract with the patient, and documenting the source of pain and treatment history will avoid problems and misunderstandings.

When considering analgesia, some methadone-maintained patients can be managed the same as those without an addiction history; however, 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 usual. This is due both to high opioid tolerance and 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) provide negligible analgesia and, in higher doses, accumulation of metabolites can 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 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 (as of 2/2004).

Methadone maintenance treatment is NOT a contraindication for the appropriated use of psychotropic medication in the 60% of patients, or more, with addictive disorders having Axis I psychiatric comorbidity. While most psychotropic medications have interactions with methadone, which can be consequential, and some 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 administering medications, if appropriate.

Regarding the dually-diagnosed patient, discontinuation of methadone maintenance treatment is contraindicated when stabilization of psychiatric symptoms or pain can be attributed to methadone. Substantial evidence exists that methadone itself may engender potent psychotropic benefits as an antidepressant, antipsychotic, and stabilizer of labile affective states. Finally, there are no contraindications for stabilized OTP 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 enzymes, propensity for accumulation, 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/methadonedruginteractions.shtml

http://www.atforum.com/cardiacmmt.shtml

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 discussions of clinical issues or a transfer of records regarding our mutual patient is required, please have the appropriate release of information requests signed and contact us.

Sincerely,


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This page last revised February 18, 2004 by

Ralf Gerlach
INDRO e.V.
Bremer Platz 18-20
48155 Münster
Germany
Phone: +49 251-234577 or -60123
Fax: +49 251-2807687 or -666580
Email: INDROeV@t-online.de