While
this particular topic is fraught with ethical considerations, it is
imperative to try to lay out the most useful and ethically based principles
when a patient must be involuntarily withdrawn from  methadone
due to inability or unwillingness to pay the established program fees.
The following considerations are important to establish before any
methadone maintained patient is involuntarily withdrawn by the treatment
program from his/her stable dose of methadone.
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The
program has informed the patient at the inception of treatment
what his/her responsibilities will be in paying for treatment. |
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The
patient has been informed verbally and in writing of the established
fee schedule. |
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The
patient has also been informed both verbally and in writing
what will happen if they are unable to pay the established fee
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Should
the methadone program in question be a member of AATOD, either through
the state membership structure or as an individual provider member,
the provider is expected to follow AATOD's
Canon of Ethics. There are two particular elements of this Canon
of Ethics that are applicable to the guidelines under consideration.
Dosage
Reduction Principles
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If
an administrative decision needs to be made to involuntarily
withdraw the patient from methadone as a result of non-payment
of fees, the dosage withdrawal schedule should be conducted
in the most humane manner possible and in accordance with sound
medical treatment and ethical considerations. |
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No
set dosage reduction schedule should be established for all
patients. Illustratively, a patient who is being maintained
on 100 mg of methadone would need a longer time to withdraw
than the patient who has been maintained on a 50 mg dosage.
Obviously, the higher the dose level, pre- withdrawal, the longer
it will take for the patient to safely and humanely withdraw
from methadone. |
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Some
patients may be able to tolerate more rapid dosage reduction
schedules than others, and such reductions should take individual
patient responses into account prior to proceeding to the next
dosage titration. There are mitigating factors such as a patient's
psychiatric and other medical comorbidities. An accelerated
dosage reduction schedule could potentially place the patient
in medical crisis depending on pre-existing cardiac or other
chronic illness (epilepsy). Such rapid withdrawal schedules
need to be carefully monitored by all appropriate clinical personnel
within the treatment program. |
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It
is also recommended that program admissions staff carefully
evaluate the patient's ability to pay for treatment. The patient
may have the ability to pay for treatment for the first several
weeks but not have any ongoing or steady method of paying for
care. While circumstances change, the program should exercise
good judgment to the best of its ability in ensuring that the
patient has the ability to pay for treatment as a method of
avoiding a potential involuntary discharge as a result of non-payment
of fees. This does not in any way "absolve" the patient
of his/her responsibility to meet established and agreed upon
fee payment. |
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It
is countertherapeutic for OTP program personnel to withhold
methadone maintenance dosages for lack of fee payment on any
day, when it is not part of a documented and established dosage
withdrawal schedule. Illustratively, it has been reported
that some OTP staff may withhold a patient's daily dosage
of methadone if they do not have the daily program fee. This
only disrupts the patient and does not represent a therapeutic
practice. It is to be avoided at all times.
In
closing, the issue of administrative withdrawal from methadone
for non-payment of fees is one of the most critical issues
of importance to patient advocates throughout the United States.
Our Ethical Canon is clear in providing general guidance on
the matter in addition to published literature about methadone
treatment.
AATOD
urges treatment providers to use all due caution when entering
this arena.
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