The prevailing dosing model in methadone maintenance treatment (MMT) supports adjusting methadone doses downward, based on signs of opioid intoxication, or upward, based on withdrawal signs or patients’ reports of craving or illicit opioid use. But a recent study, carried out at the Albert Einstein College of Medicine (AECOM) and Montefiore Medical Center, suggests that these guidelines “may not resonate with patients’ understandings, beliefs, or feelings about appropriate doses.” The authors propose an alternative strategy: a model that takes into account patients’ perceptions about methadone doses, and the meanings patients associate with treatment. An underlying but unstated component is increased communication between patients and caregivers. The authors believe their model will improve adherence and enhance MMT success.
Published online June 25 in the Journal of Addiction Medicine, the study found that “perceptions about methadone dosing influence treatment effect at different doses”—the “meaning effect.” The proposed model is not a protocol for selecting ideal doses, but a way for caregivers to look at factors that influence patients’ ideas of “comfort” and “function,” and the dose ranges patients consider comfortable. The figure below summarizes the concepts behind the model.
- 19 participants recruited from a waiting room at the MMT clinic at the AECOM
- 10 men, 9 women
- Most were 40 years or older (range, 29 to 60)
- Hispanic, 11; white, 5; black, 2; Native American, 1
- Most had been using heroin for more than 10 years (none were being treated for prescription opioid misuse)
- 15 were previously in MMT, usually followed by relapse
- Daily methadone dose: 50 to 280 mg; highest ever: 60 to 290 mg
The authors considered the sample size adequate because late interviews produced no new themes—a situation known as thematic saturation.
Perceptions About Methadone Dosing. Data from transcripts of semistructured interviews reveal that “the perceptions of methadone and MMT formed both before and during treatment shape the dose that an individual patient feels is appropriate and/or comfortable.” Interestingly, participants’ perceived “ideal” methadone dose was 0 to 195 mg—much lower than their current dose.
Participants described ideal dose in terms of their “function” and “comfort,” eg., “I feel normal . . . and that helps me maintain my own activities throughout the day.” “I feel comfortable on 140 mg so I can function.” They said that doses too high or too low compromised their overall function, and viewed high doses as “an obstacle to discontinuing methadone treatment in the future.”
Discussed below are factors that influence the dose range in which patients seem best able to function.
Factors Favoring a Decrease in “Ideal” Dose Range
Factors Directly Related to MMT
- Lack of taking part/lack of control in treatment
- Disdain for getting high on methadone
- Concerns about methadone dependence
- The idea of doses being “too high”
- A desire to avoid adverse effects (eg., nodding off)
What participants perceived as their lack of control often made them feel like stopping treatment. They used metaphors of incarceration, such as calling MMT “a life-long sentence.” They saw automatic dose increases triggered by “dirty urines” as unfair—a unilateral control issue. One commented: “they are not asking me why am I still getting high.”
Most participants equated methadone intoxication with intentional misuse. They wanted doses that reflected methadone as a medication rather than a “drug.” Almost all viewed methadone treatment as temporary, so they did not want to become dependent.
Participants expressed “seemingly arbitrary” ideas about dose. More than half felt that their ideal dose was “50% of their current dose or less than that.” They viewed patients who took high doses as “crazy,” “greedy,” or “abusive.”
Factors Indirectly Related to MMT
- Stigma around and shame about MMT; some didn’t feel “clean” when taking methadone
- Some felt ashamed about being on what they considered a high dose
Factors Favoring an Increase in “Ideal” Dose Range
Directly related to MMT: Some participants expressed concerns about possible withdrawal symptoms (“dope sickness”). Indirectly related: Some saw certain co-administered medications, chronic pain, pregnancy, or stress as reasons for needing higher methadone doses.
Clearly, factors favoring a decrease in dose range far outnumbered those favoring an increase. This was in line with participants’ perceptions that their current dose was much higher than their ideal dose.
Factors Exerting Mixed Pressures Over “Ideal” Dose Ranges
- Family and friends were likely to make participants feel they should be on a lower dose, or even off methadone. Alternatively, they could have a stabilizing effect by motivating patients to stay in treatment.
- Methadone formulations drew mixed responses. Many considered “orange pills” the strongest. Some saw “white pills” as relatively strong; others considered them weaker (“I was still feeling urges.”). The liquid methadone dispensed at the clinic drew comments such as “hits you quicker” and “holds much longer.”
The authors suggest that their MMT model will add nuance to understanding “the acceptability (and, perhaps also, the effectiveness) of certain doses,” and help lead to a more patient-centered understanding of undermedication and overmedication. This would enhance clinicians’ “sensitivity to the patient experience and foster greater adherence to and success in MMT.”
Justin J. Sanders, MD, MSc, formerly a chief resident in family and social medicine at Montefiore Medical Center, is now a palliative care fellow at Harvard Medical School. Dr. Sanders received a Chairman’s Award for Research as a result of the work that led to this publication.
Sanders JJ, Roose RJ, Lubrano MC, Lucan SC. Meaning and methadone: Patient perceptions of methadone dose and a model to promote adherence to maintenance treatment. [Epub ahead of print June 25, 2013.] J Addict Med. doi:10.1097/ADM.0b013e31829702le.