Serum Levels & Split Dosing
Dr. Marc Shinderman, Center for Addictive Problems (CAP) - Chicago
Dear Doctor:
About three months ago, I got on a methadone maintenance program. Instead of being started at the standard 40 mg, I was started on 20 mg--I think because I was so high when I went in there, I'm not sure. Anyway, 20 mg was fine for the first week, then I started getting sick in the morning. I kept increasing my dose 10 mg at a time, and the same thing would happen. The dose would hold me fine for about 5 days, then I would start waking up sick. I was up to 100 mg, and I was still waking up sick in the morning. I dose at 8:00 a.m., and by 3:00 a.m. the next morning, I'm sick as a dog.
When I wanted to go up again, they didn't believe that I was sick, so they drew some blood to see what my methadone blood level was. As I suspected, it was low. They told me that because of my metabolism, I'm a "fast metabolizer", and my body is running though the methadone "very quickly".
The people at the clinic tell me that if I keep going up, I will eventually find a dose that holds me for the full 24 hours.
At the dose I'm at, already I can't take the constipation. I have to take six stool softeners, a gallon of water, and 1-2 enemas A DAY if I ever want to have a bowel movement.
I never had so much trouble on heroin. My psychiatrist (who, by the way, was the medical director of the same clinic from '75-'85) tells me that no matter what dose I go up to, my body will adjust, and I'll ALWAYS get sick in the morning. He recommended that I detox. I went down to 95 mg about three days ago. Mind you, I was already getting sick on 100 mg/day. From about 2:00 a.m. until my dose, I'm in full-fledged withdrawal.
What should I do? Is it true that I won't ever reach a dose that holds me? The catch-22 is that at the dose I'm on, I can't tolerate the side effects, but it's not holding me 24 hours. I can't go up; I can't go down. Because my metabolism is so fast, I requested a "split dose", but because I'm new to the clinic, they won't trust me with any evening take-homes. I'm so screwed. I need some advice. I'm much worse off than when I was using heroin: Now, I have to go through withdrawal every single day of my life. I want to blow my head off. - Matt
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Dear Matt:
Relax. Your problems are not impossible ones.
1. Senna or Sennatural or Senekot is the best stool softener for most of my patients. Take it. Get your dose divided.
2. What we do at CAP in such cases is divide the dose in two or three portions. At first, I would advise 50 mg in the morning and 50 mg as long after as you can handle feeling comfortable. The first day, I would recommend 100 mg as usual, 50 mg 12 hours later, then 50 mg the next morning and afternoon from then on.
3. You should protest it to the regulatory agency in the state and FDA and protest it to the people who give the MD his license if they do not respond adequately. If the clinic says that this is against the "rules", they are mistaken or they are talking about their rules, which should not prevent good medical treatment. The doctor can ask the regulators for an exception due to your medical situation. The low serum level is in the record. Your complaint of constipation is serious and not unique.
If they do not trust you, they should arrange for you to drink your medication 2 times a day, observed. This anti-patient treatment is what drives patients back to smack. It is unethical. The "rules" cannot be applied with clinical success to every person, and the FDA will grant exceptions to them.
4. You should go to a clinic where they give you a take home split dose. As a second very stupid but possible solution, you should go to a clinic where you could dose observed twice a day, 6 hours apart, or more. (At CAP we medicate 5:30 am to 7 p.m., for example). We get exceptions for split doses for new patients every few weeks or so. We do it to get their serum levels up and keep them from using heroin. We think that is the main job that we have. Everything else is secondary. Being able to hold off on your dose, from time to time, may help with the constipation (along with the Senna and water).
5. Try LAAM at 120 to 140 mg. Yes, I said LAAM, ORLAAM. Some patients like it better than methadone. You may be one of them and it is worth a shot. You are near to relapse--a better choice than what you feel like doing: ("I want to blow my head off"). Use all the tools available to hold on to your health. LAAM is one. Why? Keep reading.
a. you only go to the clinic 3x a week (if it is a good clinic, you can choose to see your counselor or get what you need from it anytime. If it is lousy, as I infer from their mistreatment of you, enjoy the break from their ignorance.
b. it may not give you constipation.
c. it holds fast metabolizers longer.
d. if you do use opiates, it has no consequence on your clinic schedule. You come 3 days a week, using or not.
e. LAAM will cost the clinic 300 percent more than methadone, which might give you some twisted pleasure. You deserve some revenge.
You ask if it is true that you won't ever reach a dose that holds you. No, that is ridiculous. You may need to see an actual MMT professional physician who knows how to medicate patients. You have no real problem that common sense cannot deal with. Hold on.
While you are waiting for rational care you can try the dopey but practical stop gap measures of taking meds that will help you on the screwy regime that you are on (100 mg/D single dose).
You can take a few tabs of over-the-counter Tagamet, the generic is cimetadine, and you can use a small dose of clonidine at the time when you feel that you are feeling "funky" or might otherwise describe the moment that you know that you will not be feeling great in an hour or two. If you take clonidine when you feel okay or 4 hours before your dose or 8 hours after, it can make you pass out. You should have an MD prescribing the clonidine and she will advise you of the risks which are real. Do not take clonidine from a friend. Your brains CAN "BLOW OUT" if you take a lot for a few weeks and then stop suddenly. It is not candy. It is not benzos. It is blood pressure medication. It works.
Finally, if none of the above works out, you should come to our clinic, and we will transfer you back as soon as possible--stabilized. What you have to lose in relapse or blowing your brains out is well worth whatever it takes to spend a month or two in Chicago.
(Tell me about what medications, alcohol or drugs that you may be taking now. If "some," there may be different answers than the ones above. Ditto for hepatitis or anti HIV meds.)
Dr. Marc Shinderman
Center for Addictive Problems (CAP)
Editor's Note: We are delighted that Dr. Shinderman has joined our Medical Advisory Board. His should be the standard for all methadone clinics. The patients are the most important people there, and it is not an inconvenience to them to get the patient properly and correctly dosed. Thank you, Dr. Shinderman - Beth Francisco, Editor
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