Saturday, May 10, 2008

PEAK-TROUGH TESTING:

We've been copied on correspondence involving a long-time methadone patient who has not been doing well on doses that very slowly and grudgingly were raised to about 80-mg per day. The "clinic" insisted she have peak-trough blood concentration testing done - and pay for it! Based on the results they claim there's no rationale for increasing the dosage and instead are threatening to decrease it. Some comments on peak-trough testing follow:

Tom Payte is the expert on this... My understanding: peak-trough relationship merely indicates that one might have a "fast metabolizer". It's indicated not to determine adequacy of dosage, but to help formulate response to patient discomfort and less than optimal therapeutic results.

If one has a patient not doing well, and there's a big big gap between the peak concentration and the lowest in the course of a day, then it might make much more sense to split the dose rather than "just" increase it. In fact, increasing it in such cases might lead to more discomfort/problems, because there'll be a higher peak, still a very rapid metabolism and thus in the course of the day an even greater gap between the high and low concentrations. Thus: rationale for splitting doses - I've heard Tom Payte talk about some (very few) patients whom he had to give doses six times a day before they responded well.

I see zero rationale ever for decreasing a dose based on P-T levels. Ultimately, I'm a believer in clinical observation rather than fancy and expensive lab tests. Patient's dojng well on a dose, great. If not, and most definitely if patient has been getting dosage that for most is sub-optimal (e.g., less than 80) then of course increase the dose! It's when the dose gets up[ to 150-200 and the patient still reports doing poorly, especially toward end of day, then logic dictates trial of splitting the dose - say half AM and half PM. What counts is how the patient is doing - NOT what a lab test shows (identical reasoning for my disdain for urine tests!).

14 Comments:

At 5:49 PM, Anonymous Anonymous said...

hi dr. wish i could get my clinics Dr. to think even in your neighborhood. from the beginning she starts with 5mg increases she never increases by 10mg and i can say that after 4 months i have jsut today gotten to 85mg and this last 5mg increase i got today has taken a month and a half. she said no to my begging about 4 times . this clinic doesnt believe in adequate dosing. I have never heard anyone at thias clinc say well maybe your ill because you need an increase. What they really want to be is a treatment ctr but that doesnt rake in the dough. In their mission statement in our clinic booklet they say that within 2 weeks using no illicit drugs everyone should be fine on 50mg or less. AGENDA> They say they have no dose cap but thats cause you cant get near adequate. I even had a trough test that was low, why did she give me a 5mg increase right after i took the blood test before the results were even back? the nurse said i had to take a trough test and then i could have a 5mg increase.

 
At 3:42 PM, Blogger Garrett said...

Absolutely criminal, but sadly all too common practice these days. If any other area of medical practice prescribed less than optimal doses (in your case hideously subtherapeutic!) the doctor would likely find himself answering the boards on a charge of malpractice. Opioid dependence seems to have different rules where many patients are treated appallingly (or not at all!).

 
At 8:20 AM, Blogger christian said...

DEAR DOCTOR I AM A FIRM BELIEVER IN YOUR WAY OF THINKING. BEING A MMT PATIENT OFF AND ON FOR 30 YEARS I DETOXED FOR 2 YEARS IN 98 &99 i WAS IN A HORRENDOUS CAR ACCIDENT AND HAD 21 ORTHO SURGERIES AND WAS ADDICTED TO A WHATS WHAT IN OPIATES. i WENT TO PAIN MGT. TO STOP ALL THE PILLS AND A WASTE OF MONEY. aFTER i WAS INCREASED TO 100MG i WAS STILL WAKING AT 3 AM DYING TO TAKE MY TAKE HOME DOSE. oUR DOC DID 2 BLOOD LEVEL TEST AT 100 MG IN 23 HOURS PERIODS.HE WAS ASTOUNDED BY THE BLOOD LEVEL WHICH WAS ALMOST METABOLIZED TOTALLY SO HE SENT IT TO ANOTHER LAB SAME RESULT. I AM A FAST METABOLIZER AND THE TESTS PROVE IT ANYWAY i WAS RAISED TO 180 MG AND IT WAS SPLIT IN 80 MG. EVERY 12 HOURS. I HAVE BEEN ON THAT DOSE SINCE MARCH 3 99 AND AM STILL CLEAN AND DOING GOOD OVER 8 YEARS LATER THANKS FOR DOCTORS LIKE YOU C RYAN

 
At 10:54 PM, Anonymous Anonymous said...

I have read studies that show the higher the dosage, the more successful the program will be. And I've seen this first-hand. My female friend(5'7, 140lbs) takes 400mg per day, and no longer adds heroin to the daily mix (as she did when she was between the 200-300 range. She has Hepatitis C and a fast metabolism. After about ten hours she was starting withdrawal symptoms, so they raised her dose and allwed her to split it. Liver problems are a problem for people on Methadone Maintenance, some just need a higher dosage than normal. My spouse is on 290mg per day; (male, 6'3 200 lbs) he too has liver damage. However, one major benefit of higher doses is the lack of desire for pills, heroin or alcohol. These two people were alcoholics for years... and now they do not drink, do not have cravings and if they did do heroin or other opiates they would not get 'high' because their little opioid receptors are full.

 
At 4:08 AM, Blogger lilgirllost said...

I have been a MMT pt for over 8 yrs. I have been at 120mg daily for over 3 yrs, have put on about 50 lbs (I know weigh 235) and have been going through some things that are causing me a lot of stress. I crave, have trouble sleeping and when I do, I dream about pills and even dream about methadone (getting more, taking a bunch losing mine and freaking out....etc) For the last several months (prob 4-5 mths), I have been having withdrawl symptoms starting late in the day and sometimes they have gotten so bad that I end up taking my take home doses just to get through the day. My clinic refuses to even "consider" an increase until I have a peak and trough test (which I have to pay for myself $130). They told me there is a "cap" at 120mg and say there are new studies about doses over 120mg causing heart problems in some patients..........(has anyone else heard of THAT?). I am not opposed to a P & T test, but you would think that after being on the same does for over 3 yrs they would believe me when I say that I am having probs and need an increase. It kinda makes me feel like they think I am a liar. It is so frustrating to me. I am a pt that hasn't had a bad drug screen in like 5 or 6 yrs and always pay 6-12 months in advance with our income tax refund. They are constantly going up on their fees and I mean, what am I going to do??? Just like a drug dealer who goes up on his price??? I NEED the substance so I am going to fork out the money no matter what. I sometimes feel like they are a legal drug dealer and don't really care about me, my needs or my feelings, that as long as they get their money then they don't are about anything else. Sorry to rant, it is just so frustrating to me and I know there are others out here in cyberspace who probably feel the same way. SERIOUSLY, have any of you heard of new studies showing a dose over 120mg causing heart problems???

 
At 10:03 AM, Blogger RGNewman, MD said...

Thanks for contacting us. First, we (and a great many people in the field of addiction treatment with methadone feel it is wrong to impose any arbitrary dosage limits; dosages should be individualized based on how the patient is doing. Nothing about cardiac problems, as far as we kniow, argues against an optimal dose of methadone - "optimal" determined, again, by how the patient responds.

As for the peak and trough testing - it does seem to be strongly indicated in a case such as you describe. If the difference in highest (peak) and lowest (trough) concentrations of methadone is very great - sometimes attributed to very rapid metabolizers of methadone - then the best course might be to split the dose rather than increase it. Of course, before agreeing to (and paying for!!) the testing, you should make sure just what the physician-=in-charbge will do with the results. If s/he rejects split doses (the way, apparently, s/he rejects the notion of doses above 120mg), then there's no point at all in the testing. That would be unfortunate, however, since as indicated, there are patients for whom split-dosing is the best - sometimes only - way to deal with the type of symptoms you describe. I gather your difficulties are not new, and have not been addressed. Hopefull they will be now . . . good luck . . . .

 
At 2:55 AM, Anonymous Anonymous said...

Every study done clearly shows higher doses make for cleaner patients. I was on 250mg for over 7 years and never had one dirty test. I detoxed and have been fine. I never nodded on my dose I went back to school and it saved me. If a person is saying they need a higher dose they usually do of course there are those that just want to get high, but they are easily spotted. They are usually the ones that have to be woke up by their counselor at appt time. Good Luck

 
At 6:24 AM, Anonymous lilgirlost said...

hello again. I wrote a while back & told of how my clinic was requiring me to take a peak & trough because my dose of 120mg that I'd been taking for over 4 yrs was not working for me anymore. Here is what happened. IO will have to break this up into multiple post because post is too long so PLEASE bear with me! My trough was 263ng/ml & 4 hr peak was 508 ng/ml. The doc decided that I was OVER medicated. not only DENYING an increase but DEcreasing it as well. I had kept a journal for a week to try & show him what I'd been going thru with the withdrawls & cravings, he never even looked at it or wanted to discuss it. I've presented to the clinic mgr on several occasions before the P & T w/physical w/d symptoms that she aknowledged (but I find out now was never documented because I never "told" them to document it!?!) The doc was like a ROBOT! All he kept saying was "I can not increase you over 120mg because according to this chart you're levels show you are OVER medicated. If you don't like it, you can go to another clinic." When I asked him what do you do to other ppl like me who have been going to your clinic for 8 yrs or more & need to go over 120mg? He said "if their P & T looked like mine and I couldn't handle the dosage then maybe it was time to get off anyway." I am NOT exaggerting any of these things this man said to me in any way and I WISH TO GOD I had a tape recorder when I went in there. Continued in next post....

 
At 6:29 AM, Anonymous lilgirllost said...

I also want to add, the day I went to actually have the P & T done, I should have KNOWN something was up because I was told I would have to pay 130 for the test originally, but the director "graciously" decided to not charge me for the test. I don't care what anyone else says or thinks, I think she did this AND did not document my w/d signs that she observed because she KNEW they would not go over the 120 and that way I would have NOTHING to back up my claims if I tried to file a grievance. This woman is a tyrant about money and for her to let me have a test that she normally charges that much for for FREE! I even went home that day and joked with my husband about it and we laughed......I am NOT laughing now!
When I told her that I would file a grievance because he CAN NOT be the last word on this, the director told me I could do that if I wanted but she wanted me to know that the state does not get involved when it comes to doctors decision on dosing and money because they will not overturn a dr's decision about dosing. She also told me that the doc very rarly goes over 120 mg and then only when someone has severe liver problems and/or hepatitis. That tells me right there she had a good idea how this was going to come out. I don't know if she is telling the truth about what will happen if I file a grievance or not, but if so, this is SO unfair. I just want a doctor who actually keeps abreast of new info with an open mind to look at my situation and give another opinion and if my current doc is RIGHT then give me some OPTIONS and help me try to figure out what to do to fix this. Not just, "well, if you don't like my decision, you can go somewhere else" especially after I have gone to this clinic my whole 9 yrs of treatment where, again I am not exaggerating, I have been a model pt. I have never given them ANY problems, I have paid my fees with our income tax refund a year in advance for the past 4 yrs and I have had only 2 pos. ua's the whole time and only twice struggled with my take homes doses (again trying to self treat my w/drawls and cravings) and and had to have it replaced because I ran out before I should have.

 
At 6:30 AM, Anonymous lilgirllost said...

I have no other options here and I feel like they are setting me up to fail after all these years of being clean. The med nurse told me she would get fired for telling me this, but I am NOT the only one having this problem right now and she also told me it only take "one good client who never causes trouble to get the ball rolling here with a complaint" but again, I think the director was looking ahead just for that and that is why I have little or NO documentation to back up my actual w/d symptoms and complaints about needing an increase. There is even no actual Request form filled out by me because it was time for my physical and the director told me, Oh, don't worry about filling one out, just talk to the doc when he does your physical". SO I have nothing other than the one week diary I kept of my day and my w/d symptoms. One other thing I forgot to mention, I have been a once a month take home client the last 4 yrs as well, so I had a little more leeway with how I actually take my meds. When I first started having physical w/d (not just the mental ones but actual physical ones) I tried to split my dose in two doses. I did that for about 3 weeks w/no difference so I then tried 3 times a day and still did not notice much difference. one 40mg tab seems to last me about 5-6 hrs and that is it. I even tried drinking grapefruit juice with it because I heard that would help make it last, but I noticed no difference there either. I am frustrated, angry and very much afraid. Methadone saved my life, my marriage and our family and I have been clean too long to fail now because some doc doesn't want to work with me and treat me like an individual, he wants to treat me like a number in one of his obviously outdated books. I would love to hear your take on this. I will quit now because I am sure my post is so long that most ppl have given up reading the whole thing but if anyone out there has finished it, I would love to hear what you have to say.

 
At 6:36 AM, Anonymous lilgirllost said...

wanted to clarify a stmt I made in my looong post.

When I said "I have paid my fees with our income tax refund a year in advance for the past 4 yrs and I have had only 2 pos. ua's the whole time and only twice struggled with my take homes doses (again trying to self treat my w/drawls and cravings) and and had to have it replaced because I ran out before I should have." I should have reinterated I have paid in advance for 4 yrs and during my over 8 yr treatment at this same clinic I have only had the 2 pos ua and the 2 times I had problems w/ taking my take home doses ahead of schedule to self treat my w/drawls.

 
At 4:24 PM, Anonymous Methadone Detox said...

I also feel that my 6 years on methadone was an improvement from using heroin on the streets. Though I like someone else that posted here gained over 100lb in the first 3 years on it. By year two and three the depression and lack of motivation was so bad that I became a recluse. I actually ended up detoxing off of methadone using a substance not so well known in the US called Ibogaine, and it worked wonders for me.

 
At 8:18 PM, Anonymous Anonymous said...

Hi me and my wife are at 149mgs we did a peak Trogh so we can go up but it came back that we shouldnt go up Cause it can harm our bodys.But we feel Sick Arounnd 4:30pm we dose around 8:30am weekday 7:00am weekends.And the Clinic that we go to dont let us Split our dose in 2 we dont know what to do we are allready doing Groups and Councleing every week

 
At 8:13 PM, Anonymous Anonymous said...

I am also in treatment in Kentucky for three years I was stable at 150 mgs a Dr came in the clinic and detoxed everyone above110 mgs and told us if we want to go higher we had to do a p&t. I did a p& t and they told me my number was 6 I didn't understand what that means or how they can have one number to compare us by when no one patient is the same. I now am failing drug test and their answer is to decrease dose instead of realizing at a higher dose I was clean and sober. As much as we pay which is 15$ daily we should be taken seriously when we ask for increases. Our cap is 120 here then you must do a peak and trough. I believe in observing patients and considering dose increases based on patients symptoms and drug test results not a all across the board number which means nothing to us who are sick.

 

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