Numerous studies have shown that dose is one of the most important aspects of methadone treatment and that patients who are given an adequate dose, know their dose and have some influence regarding their dose do better in treatment and remain in treatment (Ball and Ross, 1994; Caplehorn and Bell, 1991; Cooper, 1992; D’Annuno and Vaughn, 1992; GAO, 1990; Parrino, 1992; Zweben and Payte, 1990). Upon entering treatment the majority of addicts main concern is the methadone. This is what has attracted them to the program and can now be used therapeutically to build an alliance of trust between the patient and the program. As the patient experiences treatment and the “wise judgements” of the program staff, they begin to look to the program for support and help in stabilizing their lives.
Thus engaging the patient in the early phases of treatment makes rehabilitation all the easier for everyone: the patient and the counselor. Discussing simple concerns about the methadone brings the patient into the treatment process. When patients are involved in their treatment, and that includes dose, the outcome is for the better.
Before a patient’s dose can be changed it must be discussed with the patient, for how can a clinician know how to adjust the dose of a patient without first acquiring information that can only be obtained from the patient. Information about the “functionality” of the patient, how they feel and if the patient has produced urines positive for illicit drugs what is happening in their lives the cause this. Should a patient be experiencing a relapse then the wise clinician will find out the causes of it and then explain to the patient that perhaps a dose increase is necessary. The patient must understand why they may need an increase and how the increase will help them “function.” A short time spent with the patient will nurture a trusting relationship.
Certainly a dose should never be raised for only one positive urine and without the patient’s consent. Laboratories specializing in toxicology admit to approximately a 7% rate of false positives. The majority of clinics provide services to approximately 300 patients. Estimating from this then every month 21 patients are falsely accused of having positive urines. Considering this and the importance that patients place on dose it should never be changed for just one positive urine. Patients would be fearful of not being able to function because they are constantly being threatened with a dose increase which they have no control.
Adjusting a patient’s dose, either up or down without first discussing it with the patient is destructive to the therapeutic alliance. Such decisions foster the us/them siege mentality prevalent in many programs. The patient becomes angry towards the program and staff. They feel infantilized, objectified and left out of THEIR treatment. The human condition may tolerate such feelings of anger and powerlessness for a period of time but eventually for their own integrity the patient must rebel against the system. The Them!
It is interesting that in the early days of methadone treatment patients felt a pride and ownership towards their program. This was in spite of the many studies that patients were involved in. And perhaps that is the key — they felt as though they were ‘involved’ and an important part of making the program better. Their opinions were asked and considered. They had become engaged in the treatment process.
This past year I had the privilege to talk with Dr. Dole and the issue as to why treatment has degenerated to the point that it is no longer recognizable as the Dole-Nyswander program that was so successful. So I queried, “How did you know what to do and do it so well when you had never worked with addicts?” His remark was simple, “Well,” he said, “I had the best teacher Marie and she always taught me to first listen to the patient.”
For patients who are using other drugs a dose raise is probably in order. However, raising the dose without first discussing the reasons with the patient omits the most important aspect — the art of medicine. The patient’s concerns and even fears cannot be taken into account when their is no discussion about perhaps increasing the dose. Certainly, this is not quality methadone treatment.
References
Ball, J.C. and Ross, A. (1994). The Effectiveness of Methadone Maintenance Treatment. New York: Springer-Verlag.
Caplehorn, J.R.M. and Bell, J. (1991). Methadone dosage and retention of patients in maintenance treatment. Medical Journal of Australia (February 4) 154: 195-199.
Cooper, J.R. (1992). Ineffective use of psychoactive drugs: Methadone treatment is no exception. Journal of the American Medical Association 267(2): 281-282.
D’Aunno, T. and Vaughn, T.E. (1992). Variations in methadone treatment practices. Journal of the American Medical Association (January 8) 267(2): 253-258.
General Accounting Office (1990). Methadone Maintenance: Some Treatment Programs are Not Effective; Greater Federal Oversight Needed. GAO/HRD-90-104, 1990.
Parrino, M.W. (Chair & Editor) (1992). State Methadone Maintenance Treatment Guidelines Rockville, MD: U.S. Department of Health and Human Services, Center for Substance Abuse Treatment.
Zweben, J.E. and Payte, J.T. (1990). Methadone maintenance in the treatment of opioid dependence: A current perspective. Western Journal of Medicine 152(2): 588-599.