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must be involuntarily withdrawn from 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The following considerations are important to establish before any methadone maintained patient is involuntarily withdrawn by the treatment program from his/her stable dose of methadone.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 schedule. |
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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American
Association for the Treatment of Opioid Dependence (AATOD)
217 Broadway, Suite 304 New York, NY 10007 Ph: 212.566.5555 Fax: 212.349.2944 Email: info@aatod.org |