Dosage must be sufficient, typically in the 60-80 mg range, but some patients require more. In no other branch of medicine can one imagine guidelines — much less regulations — that insist on the lowest possible dosage, even if that dosage is only marginally effective in saturating the receptors. No medicine can work unless given in adequate dosage, so low-dosage programs are self-defeating. In the United States, the General Accounting Office compared the effectiveness of methadone programs across the country; the least successful were those with the lowest doses.
Duration of treatment must be adequate. In no other branch of medicine would effective therapy for a chronic disease be terminated after a fixed time. Imagine the outcry if physicians were forced to discontinue steroids and nonsteroidal anti-inflammatory drugs for rheumatoid arthritis, or digoxin for congestive heart failure. Yet some jurisdictions have mandated a time limit on methadone maintenance. Especially ironic is the view that when addicts are doing WELL on methadone, they should be terminated; one would think the opposite made more sense — that patients doing well on a drug should stay on that drug.
Patients themselves are usually eager to quit methadone — not only because of the nuisance but also because societal attitudes make them feel demeaned. Staff should DISCOURAGE terminating methadone until fully satisfactory social rehabilitation has been achieved and no heroin whatsoever has been used for at least a year. However, if a patient does terminate prematurely and then relapses, the door should be left open for immediate readmission and re-induction without punitive attitudes on the part of treatment staff.
Urine testing is essential — on site, with immediate feedback of results as an aid to the counseling process. Again, consider the treatment of other diseases. Would we treat hypertension without regularly checking the blood pressure? Or obesity without regular weighings? Especially with a patient population not famous for veracity, OBJECTIVE EVIDENCE provides the only sure milestones for measuring progress or detecting relapses.
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