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PostPosted: Sun Apr 16, 2017 1:38 pm 
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At some point, if the patient is using other substances, I’m going to resist raising the dose because I’m concerned about respiratory depression caused by benzos, or other similar risks. High doses of methadone raise risk of V fib, and mixing with cocaine increases that risk. Hanging with using friends increases the risk of using heroin on top of methadone. Drinking increases risks as well.

So the patient makes an appointment because his/her tolerance was high, equal, say, to 150 mg of methadone (the metabolism of methadone varies greatly between people, so dose does not say much about blood level, when it comes to methadone). The patient is still having some withdrawal symptoms near the end of the 24 hours, as the blood level of methadone drops lower. If that person is off other substances, I’ll raise the methadone dose. If the person is using cocaine or large amounts of benzodiazepines, I may decide that the risk of increasing the dose is too great. There are risks, of course, to NOT raising too; risks that the person will use heroin and die. If the risk of increasing is too great, the patient will often be unhappy or angry. I’ll tell the patient that if the cocaine goes, I can raise the dose higher. The patient then is motivated, because he/she continues to feel cravings for heroin, and minor withdrawal at night. Cocaine now becomes a problem for the patient, and the counselor can help the patient with that problem.

Some patients, of course, keep using cocaine. At some point, though, if the cocaine use continues, the person will be discharged. At that point they will have warnings, and a chance to follow through on recommendations. If they don’t, they will be detoxed off methadone and discharged. I try to reduce the dose over several weeks, so that the patient has a chance to stop cocaine and stay in treatment. That has happened a number of times; the patient will decide to stop the cocaine, in order to stay on methadone.

Hopefully that long essay clarifies it—but let me know if it doesn’t! I recognize that my thoughts may not reflect how all methadone-assisted treatments work. But the approach can be helpful, especially for patients who have struggled with buprenorphine treatment.


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PostPosted: Sun Apr 16, 2017 11:28 pm 
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I'm really enjoying learning more about methadone! Of course, I tend to enjoy learning things in general. I don't at all want you to change the title or main reason for the log and forum but encourage more info and stories about your expierences with the clinic.

I am confused, however on one thing. You give the example of a patient on multiple drugs including benzos. Are you saying that even if this patient came in having taken say 500 mg of oxy daily, wants to get help and is started on methadone. Are you saying this patient can only be given 30 mg per day to start? Is that because of the drug interactions? And is this a federal law? While I understand the concern for death due to the benzos, does this not pretty much put the pt. in withdrawals? And we know what happens then - the addict goes for more oxy. Of course then they fail a drug test and risk getting removed from treatment. This is such a condundrum if I'm understanding correctly. You would think there would be some latitude to get the patient "converted" to methadone without going into withdrawl from sub optimal dosing. So again law makers are able to dictate Medicare care?

Or perhaps I didn't fully understand? I'd love to know more.

As for why do people look down at methadone treatment? That appears easier to answer, at least in my view. First, there is lack of understanding. Most people only know of the stereotype that goes with it. "Junkies lined up in bad areas of town" leads that list. Most people don't know anyone who has had methadone treatment. That's in part because patients won't talk about it due to embaresment. The other huge reason is all of the regulations. They have to dose once a day by staff. In other words, this "medication" is so "dangerous" that it has to be so tightly controlled and regulated. How then can the general public think anything else of something so dangerous it is more highly controlled than any other drug that is administered!

By far, lack of understanding is the biggest problem. Then again. It's the same for addiction and suboxone. If the general public understood it even a quarter as well as we all do, the stigma would be gone. It almost takes us standing up and saying "I'm on suboxone and proud of it" - somethung I'm not yet willing to do myself. And there you have it.


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PostPosted: Sat Apr 22, 2017 10:11 pm 
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The experience in Portugal has proven the case for legalisation of drugs. As a society we need to get comfortable with the fact that a percentage of the population will have addicttive natures and become addicts to some degree on some drug. It really dosent matter what drug it is but if the drug is cheap to produce and made to a medical standard then that person has a chance like everyone else of having a worthy life. Pretty much the same way we deal with alchohol but as most know drugs are actually way safer and way less damaging re toxicity when made to a medical standard.
If the addict is kept in health and in the group then a day may come when they can move out of addiction.
There are already a number of blueprints from a number of countries, the statistics are there already it just needs to be done.


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PostPosted: Sat Apr 22, 2017 10:16 pm 
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mikib,

Couldn't agree more. Prohibition was moronic and in the 1920's, and it's moronic now.


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Fond Du Lac Psychiatry
Dr. Jeffrey Junig, M.D., Ph.D.

  • Board Certified Psychiatrist
  • Asst Clinical Professor, Medical College of Wisconsin

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