Wednesday, July 13, 2005

SUBOPTIMAL DOSAGES (still)

A colleague from Australia, Andrew Byrne, calls attention to an article in the current Brit J Gen Practice (June 05) by Strang et al. The authors surveyed private physicians in UK who prescribe methadone maintenance, and found a mean daily dose of 36.9. It's been shown consistently (no exceptions, I believe!) for many years that for the great majority of patients doses under 60 are sub-optimal, and that many patients require daily doses of at least 100mg (any many a great deal higher). It's difficult to comprehend such apparent bias against reliance on dosages that will, predictably, be associated with persistent illicit opiate use and the substantial risk of illness and death. Sure - the refusal of methadone providers to practice evidence-based medicine is almost universal, but one might have expected better from the UK, where over 50% of GPs reported treating "at least one opiate dependent person" - presumably with methadone.

So . . . anyone offer an explanation? Anyone have suggestions regarding how to address a problem that has been associated with methadone treatment for many decades despite uncontested evidence that it is wrong? rnewman

6 Comments:

At 4:44 PM, Anonymous Dan Moen said...

We must be more influential with the doctors today. Treating a heroin addict with Methadone and only giving suboptimal dosages only feeds the addicts disease process. If doctors would prescribe dosages in relation to how much heroin or other opiates a client is used to, it would solve alot of our problems that we have staying clean. I know in the US there are many clinics that have a dose cap. Its so obvious that as a society, we continue to penalize the addict and giving too low a dose of methadone for SOME clients is a set up for continued opiate abuse. Why can't we have some sort of universal treatment? I see alot of physican bias when they start someone in the methadone program. They readily share their feelings about addiction and that we should not come to a clinic expecting to be dosed at a level equal to what we were using in the first place. This keeps many addicts active in their sickness and literally scares others totally away from treatment and a life.

 
At 4:46 PM, Blogger RGNewman, MD said...

DMN: agree. It's physician bias and while its persistence over all these decades is tough to comprehend, one must keep seeking every opportunity to inform and educate. thanks for feedback. rgn

 
At 4:47 PM, Blogger RGNewman, MD said...

This comment has been removed by a blog administrator.

 
At 8:56 AM, Anonymous Anonymous said...

The ignorance and attitudes of the providers are certainly the biggest factor in this issue, but we need also consider the fact that the entire system in the US (and generally to a lesser extent in other countries...)discourages honesty and engagement by the patient in his/her own health care. In a system where the goals are determined by the provider (acting in effect as an agent of law enforcement and various social service agencies)there is neither any reason to expect a patient to understand or accept methadone maintenance nor any reason for a patient to trust the provider with the truth about their drug use.In addition, the natural desire to escape the system as quickly as possible combined with the understandable fear of sudden withdrawal at higher doses (always a risk when one is kept on a "day to day" leash with daily dispensing, especially in a system so flaky...)tends to encourage patients to do whatever they can to keep their doses low. And of course, many - perhaps most - patients seeking maintenance do not actually desire to cease "illicit" opioid use entirely - another reason why many work to keep their doses low.

These are all consequences of a system based from the bottom up on the idea that the patients cannot be trusted - a system dependent on a patient population who are denied the full rights of citizens under the law - a system staffed largely by people who neither understand the field/modality nor like the patients they treat.

PvdK

 
At 5:28 PM, Anonymous Anonymous said...

Suboptimal Dosing-
I can't understand except that physicians think they know best. I believe they should have required training before they are ever able to work in methadone clinics. They are a few exceptions but most physicians that work in the clinics are there for the money only; they know hardly nothing about addiction, nor methadone; they certainly don't care about the patient. The others are older, or have some deficit or they are foreign and really don't care, just put their hours in and leave as a lot of nurses do. I have actually seen nurses with my own eyes -when patients call for refills - they will write it down; the minute the patient hangs up they tear up the note and in File 13 it goes. If physicians knew how their nurses treated patients esp pain patients or ones with addiction problems - they should roll over in their grave but many have no idea, and many physicians don't care.
Personally, I am a patient and a pharmacist and I liked it much better when they had an amount that we could dose up to - it was a rule and no one could reverse the rule; but now they have left it up to the Doctor's discretion, giving Him all power over the patient; this is one reason I decided to go with the clinic instead of a pain clinic because I wanted no Doctor having that kind of power over my medicine. No Doctor should have that kind of power over a patient. It should be wrote in regulation - because physicians are not God and they can take an automatic dislike to a patient or become offended by something a patients says, and because of this they can take their dislike out on the patient's dose. They are only humans, although some think they are God. Then what does the patient do - bow to please the Doctor to keep his dose up or if it is a woman and this has actually happened - sleep with the Doctor to assure she gets her dose up. This is blackmail and of course I advised the girl to report it but she was afraid they wouldn't believe her because she was an addict. No, I don't like the change - it should never be left to the discretion of the Doctor alone- it gives them too much power over a person's life. Maybe if it was left to a Board of six people, maybe it be done more fairly. Personally, I think most Doctors need training badly in understanding methadone and addiction. No, it should never be left to the discretion of the Doctor alone but regulated in such a way that a person can get an increase if they meet certain requirements. Thank you.

 
At 10:00 PM, Anonymous Anonymous said...

It makes me sick people including myself have gone to a private doctor asking for help telling the doctor i need methadone to keep my pain away and keep me from using other drugs just to live a normal life and they are told we cant help u go to a methadone clinic. I have a mon-fri job and need to be there at 6am and clinics only offer dosing at 6am every morning if u cant make it to bad. What are people asking for help to do? Doctors just turn you away why won't anyone help???

 

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