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.

Dear Doctor:

This is a general letter in reference to mutual patients maintained on methadone in our opioid agonist treatment program.

Methadone Maintenance Treatment Methadone maintenance has been used in the treatment of opioid dependence for 30 years. It is the best treatment available for this disorder. The methadone maintained patient develops complete tolerance to the analgesic, sedative and euphorigenic effects of methadone. The stable methadone maintained patient avoids the opioid abstinence syndrome (withdrawal) without experiencing sedation, euphoria or impairment of cognitive and motor functions.

Pain in the Methadone Maintained Patient

Doctors who believe that the methadone provides pain relief and that prescription of opioid drugs is contraindicated, when the opposite is true, in both instances, usually mismanage patient. Because the patient is fully tolerant to the maintenance dose of methadone, no significant analgesia is realized from it** . Relief of pain depends upon prescription of additional medication, which is appropriate for the nature of the pain, including long and short acting opiates. Non-narcotic analgesics, anticonvulsants, tricyclics, selective seratonin reuptake inhibitors (SSRI's), alpha-adrenergic agonists, et cetera, can be used when indicated. If opioid medication is required, the dose will have to be at least 50 percent higher than that anticipated for non-tolerant patients, if not more.

Administration of opioid analgesics may have to be more frequent than usual, as well (q. 2-3 H, and not not q. 4-6 H, for example). If it is necessary to prescribe opioids for self-administration, long acting drugs are preferred to short acting, especially in the case of chronic pain. If short acting opioids are indicated, a week's supply of medication per prescription, with a small number of refills serves the needs of MMT patients, in most cases. If this is mismanaged, less than a 7 day supply may be indicated. Withholding pain medication is never a good practice, when it is required.

Severe opioid abstinence syndrome can be precipitated by Talwin , Stadol, Nubain and buprenorphine: milder discomfort occurs in some patients, with Ultram (tramadol). Darvon and Demerol can cause seizures in methadone maintained patients and should be avoided.

Anticonvulsants

In patients with diagnoses which call for anticonvulsants, Dilantin, phenobarbital and Tegretol should be avoided. Barbiturates induce rapid metabolism of methadone and should be avoided. If absolutely necessary, use of these drugs without causing undue suffering can be accomplished if the methadone dose is increased, even doubled, and given in divided doses, to balance the rapid metabolism that results. Valproic acid is currently the most inexpensive and useful alternative anticonvulsant, for most patients.

Methadone Maintenance and Psychiatric Disorders

Approximately sixty percent of patients with addictive disorders have other psychiatric disorders as well. Methadone maintenance treatment is NOT a contraindication to prescription of most psychotropic medications. The MD must be aware of interactions with methadone and the potential for abuse, neither of which are absolute contraindications for any class of medication, typically used in a psychiatric practice. There is some abuse potential with benzodiazepines and stimulants, but monitoring use and making individual determinations with each patient is preferable to proscribing their use, when the doctor has ascertained that alternatives are not effective. Discontinuation of methadone maintenance treatment is contraindicated in the dually diagnosed patient, in almost all cases, especially when stabilization of the syndrome can be attributed in part to MMT. Methadone has potent psychotropic benefits as an antidepressant, antipsychotic and in stabilization of various labile affective states.

Methadone Maintenance and HCV, HIV and Transplantation

Finally, there are no contraindications for stabilized MMT patients regarding treatment of hepatic disease, HIV- related illness or organ transplantation. Stabilized methadone patients are excellent candidates for treatment in regard to all of these.

If relevant, please have our patient, who may be named, above, or has delivered this letter to you, complete a release of information, in order to allow transfer of records or discussion regarding treatment, here.

If you have any questions, please do not hesitate to contact me or any of the other physician/addictionologists on our staff.

Sincerely,

_{** Methadone can be used as an analgesic, but only if the dose is increased and divided into 2 to 4 doses. The analgesic effect from each dose will last for 3 to 6 hours, only.}