Methadone Maintenance Therapy for Opioid Addiction

Treating patients in pain has challenged health care providers for centuries. Long-term use of pain medication, particularly opioids, creates a potential for physical addiction. Addiction to opiates can cause irreparable damage in every aspect of life, including personal health, family, and finances.

For certain patients, undergoing pain management in their 20s or 30s for an acute injury, condition, or procedure can begin a cyclical pattern of abuse, physical addiction, cessation of use, and relapse. During this cycle, lack of access to legitimately prescribed opioids may lead to illegal activities, accidental overdose, or drug-related accidents that affect both the user and others.

More than 20% of Americans older than 12 report nonmedical use of various prescribed medications at some point during their lifetime.¹ A large proportion of abuse involves opioid-based narcotics.

Benefits of Methadone
Methadone, a synthetic opiate whose analgesic properties were first discovered in the 1940s, was initially used to manage chronic pain. In the early 1960s, it was discovered that when taken daily at an appropriate maintenance dose, methadone benefited patients experiencing withdrawal from other opioids, including morphine and heroin.^2,3 Research findings published by the NIH associate methadone maintenance treatment (MMT) with reductions in opioid drug use, crime, transmission of viral diseases, including HIV and hepatitis, and incidence of opioid-related death and overdose.⁴ This therapy is also credited for improved social productivity.⁵

Patients enrolled in MMT programs receive methadone for treatment of physical withdrawal symptoms (nausea, diarrhea, muscle aches, sweating, irritability, insomnia, "crawly" skin, anxiety) and cravings. Yet treatment with methadone is only one part of the recovery process.³ MMT also includes counseling, lifestyle modification, and other supportive services. It is important for patients to understand that constant personal reflection, ongoing counseling, and an awareness of the ramifications of continued use of other drugs all play a role in the success or failure of recovery from addiction. Methadone is not indicated for the treatment of addiction to drugs in other classes or to other substances.

Strict criteria are in place for persons to be admitted to MMT. These may include a history of at least six months' daily opioid use, positive urine screening for opioids, and the presence of active withdrawal symptoms. During the first 30 to 60 days, when daily attendance is required, the proper methadone maintenance dose is determined. Participants are monitored regularly with urine drug screening.

An integral part of MMT is to help patients reestablish a "normal" life: stability in employment, family status, finances, and personal goals. Treatment duration is highly individualized, with some patients requiring lifelong therapy to ensure continued success in recovery.^3,5

How Methadone Works
Like the opioids, methadone acts on receptors in the brain that control pain and mood. Since methadone is metabolized in the liver through cytochrome P (CYP) enzymes (including CYP450, CYP3A4, CYP2C8, and CYP2D66), some care is warranted regarding use of other medications that may inhibit or induce substances in this enzyme class.⁷ (See table.^7-10) Patients who take other medications that are influenced by CYP enzymes should be monitored for cross-reactions and may require medication adjustment. A thorough history of medication use and close monitoring of potential medication combinations are warranted.

Methadone possesses certain unique properties. Compared with most prescribed opioids (ie, hydrocodone, morphine, oxycodone), which have a half-life averaging less than three hours, the half-life for methadone exceeds 24 hours.⁹ This, coupled with a relatively slow onset of action, allows for once-daily dosing, making methadone a particularly effective tool in opioid addiction treatment. When taken properly, methadone is safe for the body and does not impede normal functioning. Additionally, methadone is cross-tolerant with other opioid medications,⁴ decreasing the likelihood of drug-seeking behavior.

Dosing is deemed adequate when the patient experiences relief from withdrawal and cravings without feeling "high" or oversedated. Because methadone is a full agonist, however, excessive dosing may produce euphoric effects.⁹

While methadone can in itself be physically addicting, research clearly shows that this agent helps normalize the function of body systems (particularly the immune, endocrine, and neurologic systems) that were previously impaired by opioid abuse.¹

The most commonly reported adverse effects of methadone use are similar to those associated with the opioids: constipation, decreased libido, alterations in sexual functioning, amenorrhea, weight gain, and sweating. Methadone is not contraindicated for patients undergoing medical or dental procedures, but any dosing reduction should be coordinated through the MMT team. Abrupt reduction or cessation of methadone dosing may lead to drug craving and a reappearance of withdrawal symptoms.

Considerations Before MMT
For the patient who acknowledges an opioid addiction problem, the primary care provider's first step should be to attempt to wean the patient off the prescribed medication. Abruptly cutting the patient off will only generate panic and increase the likelihood of illegal behavior. If the patient is unable or unwilling to tolerate a weaning process, referral to a MMT center is indicated. To allow a reasonable time frame for the patient to enroll, providers are advised to prescribe a limited supply of the medication in question.

Methadone Maintenance Treatment
Upon admission to MMT, the patient undergoes an induction phase in which the proper methadone maintenance dose is determined by increasing the dosing every two to four days, with careful monitoring. Since methadone is taken by mouth as a pill, diskette, or liquid, the risk of exposure to needle-borne diseases is eliminated. Use of diskette or liquid formulations helps prevent diversion of medication, as does supervised consumption.¹¹

Thus, patients are required to take the entire dose in the presence of a clinic employee (usually a dosing nurse). Starting doses are generally 30 to 40 mg per day.¹² Maintenance doses are highly individualized, but most patients will require 60 to 120 mg per day to suppress opioid withdrawal symptoms and cravings.⁸ Some clinics arrange split dosing for patients who need to take lower doses more frequently.

Careful monitoring is an important feature of MMT. Because of methadone's long half-life, a too-rapid dosing increase or a drug reaction can trigger rapid elevation of methadone serum levels.⁹ Methadone-related mortality is most significant during the first few days and weeks of treatment, in part because of the use of opioids or other substances to cope with withdrawal symptoms that will subside once dosing is stabilized.

Most states require MMT clinics to register all patients in a statewide central database to prevent dosing at multiple sites.

Challenges for the Managing Clinician
One of the primary care provider's greatest concerns for patients who are receiving MMT is the treatment of pain. While NSAIDs or other nonnarcotic pain relievers may be appropriate for mild to moderate pain, severe pain will often require narcotic medication, possibly including opioids.¹³ Providers' general concern about oversedation in prescribing pain medication seems more significant when the patient has a known history of addiction. Many hesitate to prescribe adequate levels of medication for acute pain for fear of reinforcing a patient's addiction or supporting drug diversion.

Complicating this concern is a common mis-conception that methadone will provide adequate analgesia during an acute process.^4,7 To the contrary, patients on MMT who experience acute pain still require effective pain management. Although methadone suppresses opioid withdrawal for longer than 24 hours, any analgesic relief generally lasts only four to six hours. Use of opioid-classified medications will "block" the euphoric effects of the drug, but with sufficient dosing, patients should begin to experience pain relief.¹³

For severe pain, more aggressive dosing or more frequent dosing with shorter-acting agents is indicated.⁴ Methadone alone will not provide adequate postsurgical pain relief. Certain contraindicated analgesics (mixed agonist/antagonist or partial agonists) will initiate immediate and extreme withdrawal symptoms (see table).

Another common misconception is that the use of opioid pain medication may lead to addiction relapse or drug-seeking behavior. There is no evidence to support either notion.¹³ It is generally thought that the stress associated with unrelieved pain may pose a greater threat for relapse.⁵

Drug-Seeking Behavior
Primary care practitioners may also be concerned about being manipulated by patients with a history of addiction and wary of drug-seeking behavior. A careful, objective, and subjective clinical assessment of pain will reduce the clinician's chance of being manipulated. In turn, providing reassurance and discussing pain management with the patient in a nonjudgmental manner will relieve any distrust of the primary care provider or fear of stigma the patient may harbor.^13,14

Providers should coordinate care with the patient's MMT clinic and verify methadone dosing. For optimal pain management, ordering short-acting analgesics on continuous scheduled dosing is preferred over as-needed dosing.¹³

Careful documentation is essential for primary care practitioners who care for patients in MMT. Patients will need discharge information that clearly indicates dosing schedules of methadone, opioids, and other adjunct medications (eg, benzodiazepines) that may appear on urine drug screening panels. All new prescriptions should be listed on discharge forms. MMT program staff members generally work with patients before scheduled procedures or hospitalizations to avoid any disruption of treatment.

MMT During Pregnancy
Practitioners also need to be informed about methadone use during pregnancy—an area that has been studied fairly extensively. Compared with pregnant women who continue to use opioids or who attempt detoxification, those receiving MMT have a reduced risk of pregnancy-related complications (ie, miscarriage, fetal dis-tress, premature labor).^1,5 When properly prescribed and monitored, MMT provides a favorable environment for the developing fetus. Dosing levels and frequency are adjusted as the pregnancy progresses.

Infants born to women who are methadone-dependent can be safely, successfully weaned with no adverse effects soon after delivery.¹³ Methadone levels are very low in breast milk; thus, breastfeeding is not necessarily contraindicated in women undergoing MMT.

Another Option
While this article focuses primarily on MMT, it is important to note that some patients will opt for treatment with buprenorphine. Approved in 2002 for patients with opioid addiction, this agent has a reduced potential for euphoria and abuse because of its partial agonist properties.^12,15 Another advantage is that primary care providers certified in treatment can administer buprenorphine directly.

The downside of use of this agent is increased cost and lack of access to the counseling services that are such an important component of traditional MMT programs. Because research is limited in the treatment of acute pain for patients who take buprenorphine, more structure and greater caution are called for at times when opioid analgesics must be prescribed.^12,13

Conclusion
Patients living with opioid addiction experience fear of discrimination, mistrust of health care providers, and often embarrassment and despair over their predicament. Practitioners who suspect opioid addiction should approach these patients with respect but be direct about their concerns and reassuring about the possibilities offered by treatment. An improved understanding of opioid addiction and the benefits of treatment with methadone should enhance management of addicted patients in the primary care setting.     

Treating patients in pain has challenged health care providers for centuries. Long-term use of pain medication, particularly opioids, creates a potential for physical addiction. Addiction to opiates can cause irreparable damage in every aspect of life, including personal health, family, and finances.

For certain patients, undergoing pain management in their 20s or 30s for an acute injury, condition, or procedure can begin a cyclical pattern of abuse, physical addiction, cessation of use, and relapse. During this cycle, lack of access to legitimately prescribed opioids may lead to illegal activities, accidental overdose, or drug-related accidents that affect both the user and others.

More than 20% of Americans older than 12 report nonmedical use of various prescribed medications at some point during their lifetime.¹ A large proportion of abuse involves opioid-based narcotics.

Benefits of Methadone
Methadone, a synthetic opiate whose analgesic properties were first discovered in the 1940s, was initially used to manage chronic pain. In the early 1960s, it was discovered that when taken daily at an appropriate maintenance dose, methadone benefited patients experiencing withdrawal from other opioids, including morphine and heroin.^2,3 Research findings published by the NIH associate methadone maintenance treatment (MMT) with reductions in opioid drug use, crime, transmission of viral diseases, including HIV and hepatitis, and incidence of opioid-related death and overdose.⁴ This therapy is also credited for improved social productivity.⁵

Patients enrolled in MMT programs receive methadone for treatment of physical withdrawal symptoms (nausea, diarrhea, muscle aches, sweating, irritability, insomnia, "crawly" skin, anxiety) and cravings. Yet treatment with methadone is only one part of the recovery process.³ MMT also includes counseling, lifestyle modification, and other supportive services. It is important for patients to understand that constant personal reflection, ongoing counseling, and an awareness of the ramifications of continued use of other drugs all play a role in the success or failure of recovery from addiction. Methadone is not indicated for the treatment of addiction to drugs in other classes or to other substances.

Strict criteria are in place for persons to be admitted to MMT. These may include a history of at least six months' daily opioid use, positive urine screening for opioids, and the presence of active withdrawal symptoms. During the first 30 to 60 days, when daily attendance is required, the proper methadone maintenance dose is determined. Participants are monitored regularly with urine drug screening.

An integral part of MMT is to help patients reestablish a "normal" life: stability in employment, family status, finances, and personal goals. Treatment duration is highly individualized, with some patients requiring lifelong therapy to ensure continued success in recovery.^3,5

How Methadone Works
Like the opioids, methadone acts on receptors in the brain that control pain and mood. Since methadone is metabolized in the liver through cytochrome P (CYP) enzymes (including CYP450, CYP3A4, CYP2C8, and CYP2D66), some care is warranted regarding use of other medications that may inhibit or induce substances in this enzyme class.⁷ (See table.^7-10) Patients who take other medications that are influenced by CYP enzymes should be monitored for cross-reactions and may require medication adjustment. A thorough history of medication use and close monitoring of potential medication combinations are warranted.

Methadone possesses certain unique properties. Compared with most prescribed opioids (ie, hydrocodone, morphine, oxycodone), which have a half-life averaging less than three hours, the half-life for methadone exceeds 24 hours.⁹ This, coupled with a relatively slow onset of action, allows for once-daily dosing, making methadone a particularly effective tool in opioid addiction treatment. When taken properly, methadone is safe for the body and does not impede normal functioning. Additionally, methadone is cross-tolerant with other opioid medications,⁴ decreasing the likelihood of drug-seeking behavior.

Dosing is deemed adequate when the patient experiences relief from withdrawal and cravings without feeling "high" or oversedated. Because methadone is a full agonist, however, excessive dosing may produce euphoric effects.⁹

While methadone can in itself be physically addicting, research clearly shows that this agent helps normalize the function of body systems (particularly the immune, endocrine, and neurologic systems) that were previously impaired by opioid abuse.¹

The most commonly reported adverse effects of methadone use are similar to those associated with the opioids: constipation, decreased libido, alterations in sexual functioning, amenorrhea, weight gain, and sweating. Methadone is not contraindicated for patients undergoing medical or dental procedures, but any dosing reduction should be coordinated through the MMT team. Abrupt reduction or cessation of methadone dosing may lead to drug craving and a reappearance of withdrawal symptoms.

Considerations Before MMT
For the patient who acknowledges an opioid addiction problem, the primary care provider's first step should be to attempt to wean the patient off the prescribed medication. Abruptly cutting the patient off will only generate panic and increase the likelihood of illegal behavior. If the patient is unable or unwilling to tolerate a weaning process, referral to a MMT center is indicated. To allow a reasonable time frame for the patient to enroll, providers are advised to prescribe a limited supply of the medication in question.

Methadone Maintenance Treatment
Upon admission to MMT, the patient undergoes an induction phase in which the proper methadone maintenance dose is determined by increasing the dosing every two to four days, with careful monitoring. Since methadone is taken by mouth as a pill, diskette, or liquid, the risk of exposure to needle-borne diseases is eliminated. Use of diskette or liquid formulations helps prevent diversion of medication, as does supervised consumption.¹¹

Thus, patients are required to take the entire dose in the presence of a clinic employee (usually a dosing nurse). Starting doses are generally 30 to 40 mg per day.¹² Maintenance doses are highly individualized, but most patients will require 60 to 120 mg per day to suppress opioid withdrawal symptoms and cravings.⁸ Some clinics arrange split dosing for patients who need to take lower doses more frequently.

Careful monitoring is an important feature of MMT. Because of methadone's long half-life, a too-rapid dosing increase or a drug reaction can trigger rapid elevation of methadone serum levels.⁹ Methadone-related mortality is most significant during the first few days and weeks of treatment, in part because of the use of opioids or other substances to cope with withdrawal symptoms that will subside once dosing is stabilized.

Most states require MMT clinics to register all patients in a statewide central database to prevent dosing at multiple sites.

Challenges for the Managing Clinician
One of the primary care provider's greatest concerns for patients who are receiving MMT is the treatment of pain. While NSAIDs or other nonnarcotic pain relievers may be appropriate for mild to moderate pain, severe pain will often require narcotic medication, possibly including opioids.¹³ Providers' general concern about oversedation in prescribing pain medication seems more significant when the patient has a known history of addiction. Many hesitate to prescribe adequate levels of medication for acute pain for fear of reinforcing a patient's addiction or supporting drug diversion.

Complicating this concern is a common mis-conception that methadone will provide adequate analgesia during an acute process.^4,7 To the contrary, patients on MMT who experience acute pain still require effective pain management. Although methadone suppresses opioid withdrawal for longer than 24 hours, any analgesic relief generally lasts only four to six hours. Use of opioid-classified medications will "block" the euphoric effects of the drug, but with sufficient dosing, patients should begin to experience pain relief.¹³

For severe pain, more aggressive dosing or more frequent dosing with shorter-acting agents is indicated.⁴ Methadone alone will not provide adequate postsurgical pain relief. Certain contraindicated analgesics (mixed agonist/antagonist or partial agonists) will initiate immediate and extreme withdrawal symptoms (see table).

Another common misconception is that the use of opioid pain medication may lead to addiction relapse or drug-seeking behavior. There is no evidence to support either notion.¹³ It is generally thought that the stress associated with unrelieved pain may pose a greater threat for relapse.⁵

Drug-Seeking Behavior
Primary care practitioners may also be concerned about being manipulated by patients with a history of addiction and wary of drug-seeking behavior. A careful, objective, and subjective clinical assessment of pain will reduce the clinician's chance of being manipulated. In turn, providing reassurance and discussing pain management with the patient in a nonjudgmental manner will relieve any distrust of the primary care provider or fear of stigma the patient may harbor.^13,14

Providers should coordinate care with the patient's MMT clinic and verify methadone dosing. For optimal pain management, ordering short-acting analgesics on continuous scheduled dosing is preferred over as-needed dosing.¹³

Careful documentation is essential for primary care practitioners who care for patients in MMT. Patients will need discharge information that clearly indicates dosing schedules of methadone, opioids, and other adjunct medications (eg, benzodiazepines) that may appear on urine drug screening panels. All new prescriptions should be listed on discharge forms. MMT program staff members generally work with patients before scheduled procedures or hospitalizations to avoid any disruption of treatment.

MMT During Pregnancy
Practitioners also need to be informed about methadone use during pregnancy—an area that has been studied fairly extensively. Compared with pregnant women who continue to use opioids or who attempt detoxification, those receiving MMT have a reduced risk of pregnancy-related complications (ie, miscarriage, fetal dis-tress, premature labor).^1,5 When properly prescribed and monitored, MMT provides a favorable environment for the developing fetus. Dosing levels and frequency are adjusted as the pregnancy progresses.

Infants born to women who are methadone-dependent can be safely, successfully weaned with no adverse effects soon after delivery.¹³ Methadone levels are very low in breast milk; thus, breastfeeding is not necessarily contraindicated in women undergoing MMT.

Another Option
While this article focuses primarily on MMT, it is important to note that some patients will opt for treatment with buprenorphine. Approved in 2002 for patients with opioid addiction, this agent has a reduced potential for euphoria and abuse because of its partial agonist properties.^12,15 Another advantage is that primary care providers certified in treatment can administer buprenorphine directly.

The downside of use of this agent is increased cost and lack of access to the counseling services that are such an important component of traditional MMT programs. Because research is limited in the treatment of acute pain for patients who take buprenorphine, more structure and greater caution are called for at times when opioid analgesics must be prescribed.^12,13

Conclusion
Patients living with opioid addiction experience fear of discrimination, mistrust of health care providers, and often embarrassment and despair over their predicament. Practitioners who suspect opioid addiction should approach these patients with respect but be direct about their concerns and reassuring about the possibilities offered by treatment. An improved understanding of opioid addiction and the benefits of treatment with methadone should enhance management of addicted patients in the primary care setting.     

Treating patients in pain has challenged health care providers for centuries. Long-term use of pain medication, particularly opioids, creates a potential for physical addiction. Addiction to opiates can cause irreparable damage in every aspect of life, including personal health, family, and finances.

For certain patients, undergoing pain management in their 20s or 30s for an acute injury, condition, or procedure can begin a cyclical pattern of abuse, physical addiction, cessation of use, and relapse. During this cycle, lack of access to legitimately prescribed opioids may lead to illegal activities, accidental overdose, or drug-related accidents that affect both the user and others.

More than 20% of Americans older than 12 report nonmedical use of various prescribed medications at some point during their lifetime.¹ A large proportion of abuse involves opioid-based narcotics.

Benefits of Methadone
Methadone, a synthetic opiate whose analgesic properties were first discovered in the 1940s, was initially used to manage chronic pain. In the early 1960s, it was discovered that when taken daily at an appropriate maintenance dose, methadone benefited patients experiencing withdrawal from other opioids, including morphine and heroin.^2,3 Research findings published by the NIH associate methadone maintenance treatment (MMT) with reductions in opioid drug use, crime, transmission of viral diseases, including HIV and hepatitis, and incidence of opioid-related death and overdose.⁴ This therapy is also credited for improved social productivity.⁵

Patients enrolled in MMT programs receive methadone for treatment of physical withdrawal symptoms (nausea, diarrhea, muscle aches, sweating, irritability, insomnia, "crawly" skin, anxiety) and cravings. Yet treatment with methadone is only one part of the recovery process.³ MMT also includes counseling, lifestyle modification, and other supportive services. It is important for patients to understand that constant personal reflection, ongoing counseling, and an awareness of the ramifications of continued use of other drugs all play a role in the success or failure of recovery from addiction. Methadone is not indicated for the treatment of addiction to drugs in other classes or to other substances.

Strict criteria are in place for persons to be admitted to MMT. These may include a history of at least six months' daily opioid use, positive urine screening for opioids, and the presence of active withdrawal symptoms. During the first 30 to 60 days, when daily attendance is required, the proper methadone maintenance dose is determined. Participants are monitored regularly with urine drug screening.

An integral part of MMT is to help patients reestablish a "normal" life: stability in employment, family status, finances, and personal goals. Treatment duration is highly individualized, with some patients requiring lifelong therapy to ensure continued success in recovery.^3,5

How Methadone Works
Like the opioids, methadone acts on receptors in the brain that control pain and mood. Since methadone is metabolized in the liver through cytochrome P (CYP) enzymes (including CYP450, CYP3A4, CYP2C8, and CYP2D66), some care is warranted regarding use of other medications that may inhibit or induce substances in this enzyme class.⁷ (See table.^7-10) Patients who take other medications that are influenced by CYP enzymes should be monitored for cross-reactions and may require medication adjustment. A thorough history of medication use and close monitoring of potential medication combinations are warranted.

Methadone possesses certain unique properties. Compared with most prescribed opioids (ie, hydrocodone, morphine, oxycodone), which have a half-life averaging less than three hours, the half-life for methadone exceeds 24 hours.⁹ This, coupled with a relatively slow onset of action, allows for once-daily dosing, making methadone a particularly effective tool in opioid addiction treatment. When taken properly, methadone is safe for the body and does not impede normal functioning. Additionally, methadone is cross-tolerant with other opioid medications,⁴ decreasing the likelihood of drug-seeking behavior.

Dosing is deemed adequate when the patient experiences relief from withdrawal and cravings without feeling "high" or oversedated. Because methadone is a full agonist, however, excessive dosing may produce euphoric effects.⁹

While methadone can in itself be physically addicting, research clearly shows that this agent helps normalize the function of body systems (particularly the immune, endocrine, and neurologic systems) that were previously impaired by opioid abuse.¹

The most commonly reported adverse effects of methadone use are similar to those associated with the opioids: constipation, decreased libido, alterations in sexual functioning, amenorrhea, weight gain, and sweating. Methadone is not contraindicated for patients undergoing medical or dental procedures, but any dosing reduction should be coordinated through the MMT team. Abrupt reduction or cessation of methadone dosing may lead to drug craving and a reappearance of withdrawal symptoms.

Considerations Before MMT
For the patient who acknowledges an opioid addiction problem, the primary care provider's first step should be to attempt to wean the patient off the prescribed medication. Abruptly cutting the patient off will only generate panic and increase the likelihood of illegal behavior. If the patient is unable or unwilling to tolerate a weaning process, referral to a MMT center is indicated. To allow a reasonable time frame for the patient to enroll, providers are advised to prescribe a limited supply of the medication in question.

Methadone Maintenance Treatment
Upon admission to MMT, the patient undergoes an induction phase in which the proper methadone maintenance dose is determined by increasing the dosing every two to four days, with careful monitoring. Since methadone is taken by mouth as a pill, diskette, or liquid, the risk of exposure to needle-borne diseases is eliminated. Use of diskette or liquid formulations helps prevent diversion of medication, as does supervised consumption.¹¹

Thus, patients are required to take the entire dose in the presence of a clinic employee (usually a dosing nurse). Starting doses are generally 30 to 40 mg per day.¹² Maintenance doses are highly individualized, but most patients will require 60 to 120 mg per day to suppress opioid withdrawal symptoms and cravings.⁸ Some clinics arrange split dosing for patients who need to take lower doses more frequently.

Careful monitoring is an important feature of MMT. Because of methadone's long half-life, a too-rapid dosing increase or a drug reaction can trigger rapid elevation of methadone serum levels.⁹ Methadone-related mortality is most significant during the first few days and weeks of treatment, in part because of the use of opioids or other substances to cope with withdrawal symptoms that will subside once dosing is stabilized.

Most states require MMT clinics to register all patients in a statewide central database to prevent dosing at multiple sites.

Challenges for the Managing Clinician
One of the primary care provider's greatest concerns for patients who are receiving MMT is the treatment of pain. While NSAIDs or other nonnarcotic pain relievers may be appropriate for mild to moderate pain, severe pain will often require narcotic medication, possibly including opioids.¹³ Providers' general concern about oversedation in prescribing pain medication seems more significant when the patient has a known history of addiction. Many hesitate to prescribe adequate levels of medication for acute pain for fear of reinforcing a patient's addiction or supporting drug diversion.

Complicating this concern is a common mis-conception that methadone will provide adequate analgesia during an acute process.^4,7 To the contrary, patients on MMT who experience acute pain still require effective pain management. Although methadone suppresses opioid withdrawal for longer than 24 hours, any analgesic relief generally lasts only four to six hours. Use of opioid-classified medications will "block" the euphoric effects of the drug, but with sufficient dosing, patients should begin to experience pain relief.¹³

For severe pain, more aggressive dosing or more frequent dosing with shorter-acting agents is indicated.⁴ Methadone alone will not provide adequate postsurgical pain relief. Certain contraindicated analgesics (mixed agonist/antagonist or partial agonists) will initiate immediate and extreme withdrawal symptoms (see table).

Another common misconception is that the use of opioid pain medication may lead to addiction relapse or drug-seeking behavior. There is no evidence to support either notion.¹³ It is generally thought that the stress associated with unrelieved pain may pose a greater threat for relapse.⁵

Drug-Seeking Behavior
Primary care practitioners may also be concerned about being manipulated by patients with a history of addiction and wary of drug-seeking behavior. A careful, objective, and subjective clinical assessment of pain will reduce the clinician's chance of being manipulated. In turn, providing reassurance and discussing pain management with the patient in a nonjudgmental manner will relieve any distrust of the primary care provider or fear of stigma the patient may harbor.^13,14

Providers should coordinate care with the patient's MMT clinic and verify methadone dosing. For optimal pain management, ordering short-acting analgesics on continuous scheduled dosing is preferred over as-needed dosing.¹³

Careful documentation is essential for primary care practitioners who care for patients in MMT. Patients will need discharge information that clearly indicates dosing schedules of methadone, opioids, and other adjunct medications (eg, benzodiazepines) that may appear on urine drug screening panels. All new prescriptions should be listed on discharge forms. MMT program staff members generally work with patients before scheduled procedures or hospitalizations to avoid any disruption of treatment.

MMT During Pregnancy
Practitioners also need to be informed about methadone use during pregnancy—an area that has been studied fairly extensively. Compared with pregnant women who continue to use opioids or who attempt detoxification, those receiving MMT have a reduced risk of pregnancy-related complications (ie, miscarriage, fetal dis-tress, premature labor).^1,5 When properly prescribed and monitored, MMT provides a favorable environment for the developing fetus. Dosing levels and frequency are adjusted as the pregnancy progresses.

Infants born to women who are methadone-dependent can be safely, successfully weaned with no adverse effects soon after delivery.¹³ Methadone levels are very low in breast milk; thus, breastfeeding is not necessarily contraindicated in women undergoing MMT.

Another Option
While this article focuses primarily on MMT, it is important to note that some patients will opt for treatment with buprenorphine. Approved in 2002 for patients with opioid addiction, this agent has a reduced potential for euphoria and abuse because of its partial agonist properties.^12,15 Another advantage is that primary care providers certified in treatment can administer buprenorphine directly.

The downside of use of this agent is increased cost and lack of access to the counseling services that are such an important component of traditional MMT programs. Because research is limited in the treatment of acute pain for patients who take buprenorphine, more structure and greater caution are called for at times when opioid analgesics must be prescribed.^12,13

Conclusion
Patients living with opioid addiction experience fear of discrimination, mistrust of health care providers, and often embarrassment and despair over their predicament. Practitioners who suspect opioid addiction should approach these patients with respect but be direct about their concerns and reassuring about the possibilities offered by treatment. An improved understanding of opioid addiction and the benefits of treatment with methadone should enhance management of addicted patients in the primary care setting.