PART 1 of 3 ~ TO TAPER METHADONE OR SUBOXONE OR TO NOT TAPER: THAT IS THE QUESTION

This comes from JANABURSONS BLOG and the original link is
http://janaburson.wordpress.com/2011/12/21/to-taper-methadone-or-not-to-taper-that-is-the-question/



To Taper Methadone or Not To Taper? That Is the Question


Most of the patients I see who are doing well on methadone want to taper off of it at some point. Should these patients come off of methadone?

The studies show that relapse rates – and death rates – for patients who taper off methadone (and buprenorphine) are higher than for those who stay on methadone. We must remember that this is a potentially fatal illness, and the reasons for wanting to taper need to be compelling before tapering a successful patient off maintenance medication. (1, 2, 3, 4, 5, 6)

However, if you read these studies, they were done with heroin addicts, not pain pill addicts. Even though the opioid effect on the human body is the same, there may be differences between pill users and heroin users. It’s possible pain pill addicts have better rates of relapse-free recovery after tapering off methadone (or buprenorphine). We’re waiting for more information from studies with pain pill addicts that are underway.

Also, the referenced studies weren’t done with patients who were necessarily doing great in treatment. They compared patients who left treatment with those retained in treatment. There are many reasons to leave treatment, and a desire to taper and be drug-free is only one reason. Patients with strong desires to be completely clean may have different outcomes than patient who left treatment because they wanted to get high, or because they were discharged from treatment for violent behavior.

The desires of the patient are paramount. Methadone treatment can be expense and inconvenient, and unfortunately there’s still a stigma attached to it, even after four decades of proven benefit to patients. Plus, for any chronic medical condition (diabetes, hypertension) most of us prefer treatment without medications, if possible. If a patient says they want to taper, we must respect patient autonomy and begin a taper. Treatment centers can’t refuse a patient’s request to taper their dose. As the prescribing doctor to patients on methadone, I can give them my opinion of their readiness to taper, based on my knowledge and experience, but the patient makes the final decision.

I’ve seen many patients taper off methadone and Suboxone successfully. As far as I know they are still doing well. A few patients call periodically to let me know they are doing well, but for the most part, I haven’t heard from them.

I do often see patients who have relapses after tapering, because fortunately they return to treatment, rather than remain in active addiction. Then we can look at what went wrong, and learn from the experience, since they were lucky they didn’t die in the relapse.

I see differences between the patients who are successful and the ones who relapse. Overall, successful patients have done the work of recovery before they taper. In my next set of blog entries, I’ll elaborate on what I think must be done by the patient prior to considering tapering off maintenance medication. These include:

• No longer using any illicit drugs, and no misuse of prescription drugs
  
• Patients has acquired skills to manage negative emotions without the use of drugs (I’m not counting anti-depressants and non-addicting anti-anxiety medications)
  
• Patient has had extensive counseling around all issues that could ambush the patient in recovery.
  
• No ongoing physical health issues that cause pain or can be relapse triggers.
  
• No untreated mental health illness.
  
• No ongoing ties with drug -using buddies (or family members).
  
• Stable home and work environments, free from drug use.
  
• Have a plan of how to handle an acute painful medical situation so that relapse risk is minimized.
  
• Taper during a time that’s relatively free from emotional turmoil.
  
• Don’t rush the taper.
  
• Rehearse medication refusal for when the patient encounters a prior drug connection (it will happen, usually at the gas station, for some reason).
  
• I really encourage patients to be established in some sort of 12-step support group.
  

I know that last one is unpopular, and we’ll get to that in a future blog.

For the rest of this blog, let’s talk about why it’s so important for the patient to have stopped the use of all addicting drugs. The bottom line is that it increases the use of relapse back to opioid use, probably for several reasons.

First of all, there’s a kindling effect in the pleasure centers of the brain. When one pleasure-producing chemical or activity is undertaken, the desire for other pleasure-producing drugs or activities increases. For example, some people smoke more when they drink alcohol, because the two seem to go together. Another example is that of smoking after sex, or smoking after a pleasurable meal. While these examples include pleasures other than drugs, it illustrates what I’m trying to say.

Second of all, use of an addicting chemical often impairs our judgment. If a recovering opioid addict drinks alcohol, he’s likely to make poor decisions about other drug use. We don’t do our best thinking under the influence of alcohol, even a small amount. Alcohol can make nonsense seem reasonable (“I can take just one pill. I’ve been clean for so long, it won’t bother me”). Plus, an opioid addict is at very high risk to drink alcohol in an addictive and harmful way. Sadly I’ve seen too many people in recovery from opioid addiction end up dying from alcoholic liver cirrhosis.

Thirdly, for illegal drugs like marijuana, if you have to buy it from someone, that person is likely to have other drugs available for your use, like opioids. Apparently, many drug dealers have diversified their product lines.

Patients often try to argue with me, saying marijuana should be an exception. They claim they should be able to keep using it, because it doesn’t cause harm to the body, it’s natural, and therefore OK to keep using once off methadone. They’re missing the point. There’s no way I would argue the physical harm of marijuana, because I’d lose credibility. It’s much less toxic to the body than alcohol, which is legal. And yes, it is natural… but so are opium, cocaine, non-distilled alcohol, and hemlock. Natural doesn’t mean harmless.

Many people can use marijuana and not be addicted to it, but after a person develops addiction, it changes everything. It doesn’t matter if it’s legal/illegal, natural/man- made, harmful/harmless. It only matters if it stimulates the pleasure center of the brain, and marijuana does do that.

In my next blog entry, I’ll talk about the importance of having coping skills to deal with life’s ups and downs before tapering off maintenance medications.

1. Caplehorn JR, Dalton MS, et. al., Methadone maintenance and addicts’ risk of fatal heroin overdose. Substance Use and Misuse, 1996 Jan, 31(2):177-196. In this study of heroin addicts, the addicts in methadone treatment were one-quarter as likely to die by heroin overdose or suicide. This study followed two hundred and ninety-six methadone heroin addicts for more than fifteen years.
   
2. Clausen T, Waal H, Thoresen M, Gossop M; Mortality among opiate users: opioid maintenance therapy, age and causes of death. Addiction 2009; 104( 1356-62. This study looked at the causes of death for opioid addicts admitted to opioid maintenance therapy in Norway from 1997-2003. The authors found high rates of overdose deaths both prior to admission and after leaving treatment. Older patients retained in treatment died from medical reasons, other than overdose.
   
3. Goldstein A, Herrera J, Heroin addicts and methadone treatment in Albuquerque: a year follow-up. Drug and Alcohol Dependence 1995 Dec; 40 (2): p. 139-150. A group of heroin addicts were followed over twenty years. One-third died within that time, and of the survivors, 48% were on a methadone maintenance program. The author concluded that heroin addiction is a chronic disease with a high fatality rate, and methadone maintenance offered a significant benefit.
   
4. Gronbladh L, Ohlund LS, Gunne LM, Mortality in heroin addiction: Impact of methadone treatment, Acta Psychiatrica Scandinavica Volume 82 (3) p. 223-227. Treatment of heroin addicts with methadone maintenance resulted in a significant drop in mortality, compared to untreated heroin addicts. Untreated addicts had a death rate 63 times expected for their age and gender; heroin addicts maintained on methadone had a death rate of 8 times expected, and most of that mortality was from diseases acquired prior to treatment with methadone.
   
5. Scherbaum N, Specka M, et.al., Does maintenance treatment reduce the mortality rate of opioid addicts? Fortschr Neurol Psychiatr, 2002, 70(9):455-461. Opioid addicts in continuous treatment with methadone had a much lower mortality rate (1.6% per year) than opioid addicts who left treatment (8.1% per year).
   
6. Zanis D, Woody G; One-year mortality rates following methadone treatment discharge. Drug and Alcohol Dependence, 1998: vol.52 (3) 257-260. Five hundred and seven patients in a methadone maintenance program were followed for one year. In that time, 110 patients were discharged and were not in treatment anywhere. Of these patients, 8.2% were dead, mostly from heroin overdose. Of the patients retained in treatment, only 1% died. The authors conclude that even if patients enrolled in methadone maintenance treatment have a less-than-desired response to treatment, given the high death rate for heroin addicts not in treatment, these addicts should not be kicked out of the methadone clinic.
   

This piece had many good strong points and i don't think i can argue with any of them. Today is my 231 day clean and my counselor and i have discussed tapering. She told me how Doc usually does it (2mg every week or two), but said i can taper however i see fit. if i'd like to try decreasing my dose more or less we can. They also do something called a "Blind Taper" which is where you don't know when your dose is being decreased or by how much. You just listen to your body and if the symptoms are too severe your dose will be adjusted. I don't think i'd do well with the blind taper because i'm the type of person that would constantly be wondering if my dose was decreased, by how much, if i'll be symptomatic, etc.
I know i'm far from ready to start tapering. I'm too afraid to do it yet, and i don't think i've had enough time on the methadone. I'm doing exceptionally well. I've never had a positive drug test since i started going there because i quit using the day I started, but i know i'm not indestructible. Relapse is just as real for me as it is for someone who isn't doing as well as i am. With that being said i feel that if i'm scared to start tapering, its not a good idea for me. I don't want to rush my treatment. I feel lucky to be given a second chance, and if i relapse, my next time using could be my last. I have two children and a husband that need me. i can't take the risk.

Thanks so much for sharing your situation with us. It helps so much to know that there are others out there who are going through the same things. When I first started MMT, I fully intended to stay on it for a bit and then tapering off and living a life free from ALL opiates. I hoped to stay on it no longer than a year or two and then be done with it. That was my intentions, but that isn't what happened. I tried to taper three times and each and every time I would start having trouble when I got down to the last 10-30 mg. I struggled horribly and like you said, my two children and my husband need me healthy emotionally, mentally and physically and when I am in active addiction because of relapse I am no good to ANYONE, especially not them.

That was 11 yrs ago, I have been on methadone 12 yrs this coming April. While I still have hopes of getting off one day I am also a realist and I realize that I am much better when I am using MMT to control my symptoms of addiction. I don't beat myself up anymore because I am still on MMT after all these years (and I'm lucky to have a husband who supports me 100% either way) and I stopped making myself feel like a failure because I am still managing my addiction w/MMT.

If someone is able to taper and stay clean, I am happy for them and admire what they've been able to do, but if someone chooses to stay on MMT for many years and/or even the rest of their life then I am happy for then too. That is the main thing, that we still support each other no matter which way we choose to manage.