What is Methadone? Opioid Treatment Programs Today. Is Methadone Safe? Pain Clinics. Wisconsin OTPs. Methadone Maintenance Treatment 5/6/2013

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1 Methadone Maintenance Treatment Tanya Hiser, MS, LPC State Opioid Treatment Authority April 22, 2013 What is Methadone? Schedule II pharmaceutical opioid similar to Oxycodone or morphine. Binds to the mu opiate receptor and proteins in various tissues in the body. Suppresses withdrawal symptoms and opioid cravings. Also used for pain relief. When properly prescribed does NOT produce a euphoric or tranquilizing effect. Is addictive and abuseable similar to Oxycodone or morphine. Is Methadone Safe? Methadone is safe when utilized in therapeutic doses. Methadone does not cause impairment in driving, cognitive functioning, intelligence or employability. Methadone is not sedating or intoxicating when at a therapeutic dose. Patients still feel pain and experience emotions. Like ANY opioid, methadone can cause death if too much is taken or mixed with other CNS depressants, i.e. alcohol. Opioid Treatment Programs Today Today there are 1200 SAMHSA approved OTPs in 48 states, 2 territories and D.C. DEA, SAMHSA (CSAT) and individual state rules regulate these OTPs. All OTPs are also accredited by CARF or COA. OTPs Methadone is dispensed and not prescribed. Methadone is in liquid form only. Utilized for addiction only; not pain. Pain Clinics Methadone is prescribed and not dispensed. Methadone is in pill form only. Utilized for pain; not addiction. Wisconsin OTPs To be admitted into Medication Assisted Treatment, patients must be: :Addicted to opioids per DSM IV criteria; :18 years or older; :Able to tolerate methadone treatment; :Wisconsin resident; :Reside within 50 miles of the nearest clinic 1

2 Wisconsin OTPs 15 private, for profit OTPs owned by 4 different companies serving 5,000 patients. Cost of treatment ranges from $15.00-$17.00/day; Medicaid and insurance will pay for methadone treatment. Wisconsin rules more stringent than Federal. Patients attend daily and receive medication, counseling; provide UA for illicit testing. Take home doses are allowed when the clinics are closed and as the patient progresses in treatment. No more than 14 doses may leave the clinic at any one time. Medication Assisted Treatment MAT with methadone is only allowed at the 15 OTPs. Medication is only part of the treatment counseling is the other. Patient s must submit to random UA s to check for illicit substances. A medical team (physician and nursing) monitor the patients dose and symptoms. Blood draws done to test for level of methadone in system. Stages of MAT Induction start low and go slow; 30 mg initial dose. Maintenance dose is stable; counseling is focus of treatment. Tapering no specific treatment timeline. Patients can taper at any time. Slow taper equals less withdrawal symptoms. *Some people stay on methadone forever. Take Home Dose Criteria Take home privileges follow Federal 8 point criteria: 1. Absence of recent drug abuse; 2. Regularity of clinic attendance; 3. Absence of serious behavioral problems at the clinic; 4. Absence of known recent criminal activity; 5. Stability of the patient s home environment; 6. Length of time in treatment; 7. Assurance that the medication can be stored appropriately; 8. Rehabilitative benefit to the patient derived from decreasing the frequency of clinic attendance outweighs the potential risks of diversion. OTPs Phases of Treatment Phase 1 First 90 days; 1 TH dose Phase 2 Second 90 days; 2 TH doses Phase 3 Third 90 days; 3 TH doses Phase 4 Fourth 90 days; 4 TH doses Phase 5 1 year of treatment; 6 TH doses Phase 6 2 years of treatment; 13 TH doses Prevalence of Opioid Drug Use During Pregnancy Approximately 7,000 opioid-exposed babies are born each year Methadone is the standard of care for opioid dependent women Over 30 years of experience and research Does not appear to have teratogenic potential 2

3 Methadone Treatment During Pregnancy Methadone substitution is the standard treatment for heroin/opioid addiction Compared to heroin, methadone treatment during pregnancy has been associated with increased fetal growth, reduced numbers of premature births, preeclampsia, and fetal mortality, reduced risk for hepatitis and HIV, increased likelihood that the infant will be discharged to his or her parents, and increased retention in treatment Methadone Treatment During Pregnancy Improves the pregnant woman s ability to participate in prenatal care, addiction care and other treatment services Enhances the pregnant woman s ability to prepare for birth of the infant and begin making a home Reduces obstetrical complications Methadone Treatment Works Best When: Given in appropriate doses; no set dose Given in the context of prenatal care and women-centered treatment Women have outside support: General medical care Obstetrical care Psychological services Psychiatric care Support services Addiction treatment Methadone treatment for heroin/opioid addiction Clinical Consideration of Methadone Treatment During Pregnancy Potential Benefits Greater birth weight Longer retention in treatment Reduced exposure to unknown chemicals from cutting agents Opportunity to engage in other medical and psychosocial interventions Clinical Consideration of Methadone Treatment During Pregnancy Potential Risks Fetal exposure to psychoactive substance Potential for neonatal withdrawal Pregnant woman may need to move to a geographic area where methadone treatment is available May request detoxification from methadone before delivery May be too disruptive in treatment necessitating removal from the clinic 3

4 Risks of withdrawal must be explained clearly before initiated, especially that going off methadone places her fetus at great risk for fetal stress Literature on the use of methadone in pregnant women suggests that withdrawal from methadone not be performed without informing her of the dose or the rate Suggested rates of withdrawal are patient dependent Should be performed only in conjunction with obstetrician who can monitor mother and fetus Fetal death has been documented even when performed under optimal conditions, such as hospitalization and close fetal monitoring Detoxification should not be attempted before the 14 th week of pregnancy because it carries the potential for inducing spontaneous abortion (miscarriage) Detoxification should not be attempted after the 32 nd week pregnancy because of possible fetal distress and premature labor induced by withdrawal Barriers to Treatment Fear of criminal prosecution and removal of children by legal system or regulatory agencies Absence of adequate child care resources for existing children Lack of transportation services Poor access to obstetrical care Social stigmatization by medical providers Lack of treatment services addressing women s issues Methadone and Childbirth Pain After delivery, women should continue receiving their regular methadone dose Methadone is a painkiller, but the body becomes accustomed to pain-relieving qualities patients will feel pain just like anyone During labor & delivery, same choices for pain relief should be available possibly including opioid pain medications After childbirth Methadone dose should be continued daily as usual while in the hospital Breast feeding is recommended while taking methadone; methadone dose show up in breast milk but is too small in amount to affect or harm the child Breast feeding is not recommended if there is use of alcohol or street drugs or have HIV infection or hepatitis 4

5 Methadone and Breastfeeding Endorsed by the American Academy of Pediatrics and the American Osteopathic Association To minimize possible infant exposure, mother could take her dose of methadone right after breastfeeding and prior to the infant s longest period of sleep How is baby affected? At birth, infant may have slightly lower than average birth weight temporary and can usually be avoided with proper care before childbirth no smoking or alcohol Methadone crosses placental barrier so infant can experience some withdrawal symptoms during first few days Withdrawal usually develops slowly and is routinely treated by the baby s doctor Infants exposed prenatally to heroin or methadone have a high incidence of NAS Neonatal abstinence syndrome may be more severe and/or prolonged with methadone than heroin Research indicates that 60 to 87% of infants born to methadone mothers require treatment for NAS Central nervous system hyperirritability Gastrointestinal dysfunction Respiratory distress Yawning, sneezing, fever Attempt to suck frantically on fists or thumbs, yet sucking reflex may not be coordinated or effective Yawning Coarse tremors Runny nose Salivation Wakefulness Seizures Stuffy nose Hiccups Watery eyes Twitching Sneezing Vomiting Fever Hyperactivity Respiratory Distress Rubbing or scratch marks Diaphoresis Skin mottling Voracious sucking Unpatterned sucking Hypothermia Poor sleep pattern Sneezing Diarrhea Hypertonicity Respiratory alkalosis Inadequate weight gain High-pitched crying Hyperreflexia Hyperacusis Photophobia Apnea Irritability Tremulousness Onset of withdrawal can vary from minutes to hours after birth Majority of symptoms are present within 72 hours after birth Premature infants exposed to methadone have less severe abstinence syndrome relative to full-term infants 5

6 In summary, it appears that a majority of studies suggest no relationship between dose of methadone and severity of withdrawal When weighing the risk-to-benefit ratio for mother and infant, an adequate dose eliminates or reduces illicit opioid use and, therefore, reduces other risks, including HIV and hepatitis Administration of an adequate dose of methadone appears to be a safer alternative for both mother and fetus, rather than lower doses or none at all Methadone Dose and Neonatal Abstinence Syndrome Ongoing debate regarding relationship between maternal dose and NAS Often recommended to reduce maternal dose to reduce or avoid NAS Sub-therapeutic maternal dose may promote supplemental drug use and result in greater danger to the fetus Methadone Dose and Neonatal Abstinence Syndrome Current research shows that doses below 60 mg are not effective and hence not appropriate and low dose policies for pregnant patient are often associated with increased drug use as well as reduced program retention Methadone dose should be individually determined by absence of subjective and objective abstinence symptoms and the reduction of drug hunger (Kandall, 1993) Methadone Dose and Neonatal Abstinence Syndrome Current research shows that doses below 60 mg are not effective and hence not appropriate and low dose policies for pregnant patient are often associated with increased drug use as well as reduced program retention Methadone dose should be individually determined by absence of subjective and objective abstinence symptoms and the reduction of drug hunger (Kandall, 1993) The End 6