The dilution of methadone with water was initiated as a result of the first federal methadone regulations because it was believed that this policy would reduce the diversion of methadone. While initially this policy may have had an impact within a short time most prospective buyers learning that methadone was now diluted with water knew how to measure the amount of drug. Therefore diluting methadone with another solution usually sterile water has had a minimal impact on methadone diversion while creating other consequences that were not anticipated.
Comments on Diversion
Concern or rather the over-concern about methadone diversion has created a number of policies that programs and patients must adhere to while doing very little to reduce diversion. First it must be emphasized that the great majority of methadone patients take their medication as prescribed and do not sell or give it to anyone else. Therefore these policies have had a far-reaching impact on patients that are compliant.
NAMA proposes that if diversion is of such concern to the federal and state agencies that “real efforts” be made to make methadone available to everyone that needs it. Studies have demonstrated that diverted methadone is typically purchased by addicts who are not able to get into treatment for whatever reason (i.e. wait lists, documentation, cost, program policy, believe methadone myths) (John Galea, Street Research Unit, OASAS, personal communication 2003). Instead of creating policies that make program policies more rigid and controlling and thus less attractive to prospective patients efforts should be focused on how to make treatment available to everyone that needs it. With the majority of dependent opioid addicts in methadone treatment the need for illicit methadone would cease. In countries where citizens have a right to medical and health care and methadone treatment is integrated into the medical system illicit methadone does not exist. It makes no sense for an addict to pay for something that is free and easily available (M. Reisinger, personal communication, 2002).
Negative Impact of Diluting Medication
The dilution of methadone has a negative psychological impact on compliant methadone patients and therefore results in a policy that is anti-therapeutic. No other medication is diluted in such a manner. Every time that a patient gets their medication — that is often diluted in front of them — a message is communicated to them that they are different than other medical patients. Thus the program is forced to participate in a procedure that contributes to the low self-esteem of methadone patients. Former addicts may also harbor anxieties about their medication being diluted without their permission or that someone is diverting it from the clinic because they were subjected to practices like this (A Byrne, personal conversation, 2002).
Having one’s methadone dispensed in a pure form is reassuring to the patient that they are being treated like any other medical patient. Programs must come to realize that for methadone patients it is utmost importance that they be treated like any other medical patient. Diluting methadone has the potential to induce or worsen anxieties, and even minor symptoms could be thought by the patient to be due to drug effects. Thus the treatment program has become the vehicle that promotes the same anxieties that the patient underwent while on the street.
Diluting methadone also has an impact that is rarely discussed because of the ramifications. Particularly when methadone is diluted and bottled prior to the patients coming to the clinic there is greater possibility of it being diverted by clinic staff. While such instances are rare they do occur as noted in a New York Times article in which a pharmacist was siphoning off the drugs he prepared for financial reasons (11/18/01). Almost every patient in methadone treatment has at least thought about this and the possibility that nursing or pharmacy staffs were diluting their methadone. NAMA receives about eight complaints a year from patients suspicious about their medication. Since NAMA has no investigative unit it is difficult to confirm how often these instances are occurring. However, the number of complaints indicates that a problem exists and that administering methadone in its standard form reduces suspicion and is reassuring for patients that they are treated like other medical patients.
Conclusion
Therefore NAMA encourages programs to re-think their policy of diluting methadone. It is harmful to the psychic health of their patients who will become constantly suspicious of the program and motives of the staff. Ending theses policies can only help to improve the therapeutic alliance that is necessary between patients and programs and improve the quality of treatment. It will also work towards reducing the stigma and elevate methadone treatment and the professionals working in it to their rightful place as a legitimate medical procedure.
References
New York Times, November 18, 2001. Prosecutors Say Greed Drove
Pharmacist to Dilute Drugs, page 1.