Chapter 3 - Going on methadone
Methadone Maintenance Treatment: Client Handbook
In this chapter:
- How to get on methadone
- Consent and the treatment agreement
- The urine sample
- Community pharmacies
- A Patient's Guide — Avoiding Overdose in the First Two Weeks of Methadone Treatment
How to get on methadone
Depending on where you live in Ontario, you may be able to choose from a range of methadone providers, or there may be nothing available in your community. If you have not already made contact with a doctor or clinic that prescribes methadone, there are a few different ways to find out if the treatment is available in your area.
- See your family doctor. Tell him or her you think you're ready for methadone treatment. In order to provide MMT, your doctor must complete a training course that authorizes him or her to prescribe methadone. If your doctor does not have the authorization, and does not wish to obtain it, ask to be referred to another doctor who is authorized, or to a methadone clinic.
- If you do not have a family doctor, or if you prefer not to go that route, you may try a referral service. A number of Ontario communities offer drug and alcohol treatment assessment and referral services. To get the number of the referral service closest to you, call ConnexOntario's drug and alcohol registry of treatment at 1-800-565-8603. Their service is available 24 hours a day. When you call your local referral service, you will either be able to get an assessment and referral over the phone, or you will be able to make an appointment with a counsellor. The counsellor will then be able to direct you to a treatment that is right for you.
- All Ontario doctors who are authorized to prescribe methadone are registered with the Methadone Registry at the College of Physicians and Surgeons of Ontario. If you are having difficulty finding a qualified doctor in your community, contact the Methadone Registry at 416-967-2600. Let them know you are looking for methadone treatment and ask for the number of a doctor who is accepting patients in your area. Keep in mind that there are still only a limited number of doctors authorized to prescribe methadone in Ontario. If you live in a smaller community or a remote area, you may have to travel or relocate to receive treatment.
Before you can begin taking methadone, it must be decided if the treatment is the right one for you. To make this decision, your doctor, and perhaps a nurse, counsellor, or intake worker, will need to take some time with you to get to know you. This process, called "assessment," gives your treatment providers the information they need to get you started.
The way the assessment process works varies somewhat depending on your clinic or doctor, but generally you can expect assessment to look at you as a "whole person." Assessment always includes a physical examination by a doctor and a urine test to establish that you are opioid dependent. Assessment may also include a chest X-ray to check for tuberculosis, and, with your permission, a blood test for HIV and hepatitis. You can expect to be asked questions about your drug use, your physical and mental health, your home and family, your work, and you may be asked if you've had problems with the law.
Keep in mind that no one is judging you. Your doctor, and any others who interview you, are only interested in giving you the treatment that you have come looking for. Try to answer all questions as honestly as you can.
Assessment is also your opportunity to get to know the people who are providing the treatment. Don't be afraid to ask questions. Find out what you're being tested for. Ask what other services are available along with the methadone treatment. Gather the information you need to get ready to make decisions about your treatment.
The assessment helps to determine your course of treatment, and serves as a record of where you were when you started on methadone. Depending on your provider, you may be re-assessed again at different points in your treatment. Re-assessment lets you and your doctor know how you are progressing.
Providers differ in the amount of information they gather for assessment. You can expect assessment to take at least an hour, and possibly as much as most of a day.
The quicker you get through the assessment, the sooner it will be decided whether or not you're a candidate for methadone treatment. The time it takes to accept you as a client and begin treatment varies. In some places it may take as little as a week; in others, especially smaller cities and towns, it could take several months. If you're concerned about getting started, ask how long the process will take.
"My doctor has been exemplary in his behaviour and treatment toward me. Various other staff have been remarkably open-minded."
— Basil, 42, on methadone three years
Consent and the treatment agreement
Once you're through the tests, you've answered all the questions, and it's been decided that you're ready for methadone treatment, there are two more things:
- Before you receive your first dose of methadone, you must sign a consent form that allows your name to be added to the Methadone Registry database of the College of Physicians and Surgeons of Ontario. This information is kept solely to prevent clients from receiving methadone treatment from more than one doctor. Only a methadone-prescribing doctor may confirm that you are, or are not, receiving methadone treatment. No one else — not your employer, not the police, not welfare nor the children's aid — has access to this information.
- Many treatment providers ask clients to sign a contract, often called a "treatment agreement." This agreement states that you consent to treatment, and sets out the rules and expectations of your provider.
The treatment agreement defines policies regarding urine samples, drug use, photo ID, carry doses, threats, violent or criminal behaviour, and the consequences if you fail to follow rules. The agreement explains that if you show up at the clinic or pharmacy stoned or drunk, you will be asked to wait or to come back later before you can receive your dose. (This is a safety precaution, because methadone mixed with other drugs can be lethal.)
The agreement should also spell out your rights, including your right to confidentiality.
For safety reasons, your first dose of methadone at 15 to 30 mg a day is low or moderate. The effects of methadone vary depending on individual tolerance, and can be influenced by other drugs in your body.
When you begin treatment you may or may not have withdrawal symptoms for the first few days, and you may feel drowsy and/or have drug cravings until your dose is stabilized, usually within two to six weeks. During this dose-stabilization period, you should avoid driving a car, or operating heavy machinery. See here for important information on avoiding overdosing on methadone when you begin treatment.
Methadone is a slow-acting drug, which means it takes a few days to feel the full effects of an adjustment in your dose. It also means that once you are stabilized, should you miss a dose, the effects of withdrawal will come on more slowly than they do with fast-acting opioids, such as heroin.
Some clients are reluctant to increase their dose when they first start treatment. This can result in continued drug cravings, and continued drug use. The first step of treatment is to find a dose where you can stop using other opioids. Once you've reached that point, you can then taper down your methadone dose, if you wish.
For most people methadone works best when it's taken once a day at the same time every day. This helps to maintain a stable level of methadone in your body, keeping you feeling "normal."
It's rare, but some people metabolize methadone more quickly, and experience withdrawal well before they are due for their next dose. Usually an increase in the daily dose will fix this problem, but in some cases people require a "split dose," taking two half-doses 12 hours apart instead of one dose once a day. If you think you are "burning up" your methadone dose too quickly and need a split dose, ask your doctor to test the levels of methadone in your blood over the course of the day.
Methadone is safe when used properly, but it is a potent drug, and can kill. Overdoses are rare, but the ones that do occur usually happen within the first eight days of treatment. Generally, these deaths are the result of mixing methadone with other opioids, alcohol or downers, such as Valium. When you begin methadone treatment, be prepared to give it a chance to work for you. Stay away from other drugs — your life could depend on it.
Taking other drugs in the initial stages of your treatment also interferes with the adjustment of your dose. The symptoms you have when you begin your treatment let your doctor know how much to adjust your dose. Give it the two to six weeks it takes to get the dose at the right level for you. Hang in; it gets easier.
If you do continue to use drugs, tell your doctor or pharmacist. It could save your life. Also, let them know how you feel, if you have any cravings, or if you're feeling drowsy. They'll need this information to correct your dose.
A stable methadone dose is generally from 60 to 100 mg per day, and is adjusted according to your individual need. Never compare the amount of your dose with the amount someone else is getting. The dose that's right for you might be too much or too little for someone else. Each individual has a unique metabolism and his or her own tolerance level for the drug. Your dose is the right dose when you've reached a balance where withdrawal symptoms, drug cravings and side-effects are minimal. When your dose has been adjusted correctly, you should feel more energetic, clear-headed, and able to fulfill your responsibilities and pursue your interests.
"In the first few weeks of treatment I felt like every nerve was on edge. I couldn't drive my car, make any decisions, I had to practice patience just to carry on a conversation. Now I have a lot more energy than I expected. I've done everything from cutting the grass to cleaning out the attic, and yesterday, I got a part-time job."
— Jill, 40, on methadone four weeks
Costs vary depending on the clinic or pharmacy. Some may charge as little as $4 for a day's dose, others as much as $15.
If you're receiving social assistance in Ontario (Ontario Works) or disability (ODSP, or Ontario Disability Support Program), you qualify for an Ontario Drug Benefit card, which will cover some or most of the cost of methadone. If you're not on social assistance or disability, but you have a low income, you may qualify for the Ontario Drug Benefit Program through the Trillium Drug Program. Talk to your counsellor for more information about financial help.
Many employers now offer insurance plans that pay for prescription drugs, including methadone. If you have a health insurance plan through your work, know that no one will tell your boss, or anyone else, that the insurance company is paying for methadone for you. Some insurance companies pay the pharmacy directly, others require that you pay the pharmacy, then submit a claim to the insurance company, which then sends you a cheque. Either way no one at your work will ever be told that you ever made a claim for anything. It's your private and personal business. It's confidential.
For some people, there's an additional cost of methadone maintenance they may not consider. If you have to travel far to get your dose, the cost of transportation to and from the clinic or pharmacy can add up. Be prepared for this expense.
The urine sample
Like an Olympic athlete, you can expect a lot of interest in your urine. As a methadone client, samples of your urine will regularly be collected and tested for the presence of a variety of drugs, such as opioids, cocaine, marijuana, amphetamines, benzodiazepines and barbiturates. Some clinics require that you be "observed" when you are producing a urine sample. This practice is to ensure that the urine tested is yours.
Your first urine test will be part of the assessment process, when your urine will help to identify you as opioid dependent.
Once you begin methadone treatment, you will probably be asked for urine samples at least once a week for the first eight weeks. After that, if your tests are negative (no evidence of drug use), the frequency of these tests may decrease. After a year or so of negative tests, you may be asked for a sample only once or twice a month. Most of the time, these tests will be done at random. The frequency of urine testing may vary depending on your provider.
As well as showing if you have been using other drugs, the urine test will indicate that you have been taking your methadone. This is done as a safety precaution to ensure that your doses are being taken by you, and not by anyone else. Don't ever forget that a maintenance dose for you, may be an overdose for someone else. You have a tolerance for the drug because you take it every day.
Treatment providers look to the results of urine tests for signs of a continuing struggle with drug use, or as an indication of progress in treatment. For some clients, testing negative confirms that they can kick drugs, and gives them an extra boost of determination.
A positive urine test alerts your treatment providers to your drug use, and gives them an opportunity to protect your safety, or to offer additional emotional support. Some providers expect zero drug use, while others are more tolerant. Positive urine samples may delay or interfere with your schedule for take-home or "carry" doses, and will likely mean you'll be asked for urine samples more often.
If you test positive when you know you haven't used, you can request a retest. Sometimes labs make mistakes. It's rare, but it does sometimes happen that you could test positive for opioids after eating a poppy-seed bagel. Know that it's your responsibility to test negative, so stick to the sesame-seed variety.
"Some people say, ‘I would rather be out there working the street for money than to have someone watch me with my pants down peeing into a jar.' There must be a better way. It feels like discipline when you haven't done anything wrong. It's a hard one to get around. It turns people off."
— Jackie, 36, on methadone five years
More and more community pharmacies, including some big drugstore chains, are now making methadone available to clients. While doctors must be specially authorized to prescribe methadone, any pharmacy may dispense it if they choose to.
The main advantage of being able to take your methadone at a local pharmacy is convenience. You won't get the kind of support and additional services available through a methadone clinic. The degree of interest your pharmacist takes in you and your treatment may or may not extend beyond the safe administration of your dose. On the other hand, if the closest methadone clinic is miles away from home, being able to pick up your dose at your community pharmacy can make your life a whole lot easier.
For those who live in areas where there are no methadone clinics, the community pharmacy is the only way you can get MMT without having to move or spend a lot of time travelling. You'll still need to get your urine tested, but your doctor can help you to arrange to have this done at a local lab.
In cities where there are methadone clinics, some clients may prefer to pick up their dose at a pharmacy to reduce contact with other methadone clients.
When you go to the local pharmacy to collect your dose, you'll be lining up with everyone else in your neighbourhood. You may be the only one waiting for a methadone dose. If you're worried about your neighbours seeing you and knowing what you're there for, trust that the pharmacist is a professional, and will be discreet. Many pharmacies now provide a private consultation area where you can take your dose out of sight of other customers. You can also ask if you can arrange to pick up your dose at a time when the store is not busy.
If you'd like to pick up your dose at your local pharmacy, call them up or drop by and ask if they stock methadone, or if they would be willing to order it for you. Some pharmacies may be reluctant to stock methadone because they are afraid it will invite crime into their store. It's up to you and other methadone clients to prove those fears are false. Community pharmacists who dispense methadone are providing a much-needed service. Let them know you appreciate it.
If you are having trouble locating a pharmacy that will dispense methadone in your community, speak to the staff at your current pharmacy; they can help.
Understanding your rights to confidentiality in treatment can make it easier to relax and open up with your doctor or counsellor. It's important that you know that no one will be told you are in treatment, or be told anything you might talk about or reveal in treatment, except in the following circumstances:
- Information about a client is often shared and discussed among members of a treatment team, such as between your doctor and counsellor.
- When you give your consent in writing. For example, if you wish to transfer to another doctor or clinic, and need to forward your records.
- If you say something, or behave in a way that makes your doctor or counsellor think that you might hurt yourself or someone else, the law states that he or she must inform others in order to provide safety and protect lives. Incidents or suspicion of child neglect or abuse must be reported to the police or child protection agency.
- If you are facing trial and the court subpoenas your treatment records as evidence.
If your treatment is a condition imposed by the drug courts, probation or parole, or is a condition of keeping the custody of your child, you may be asked to sign a form that waives some of your rights to confidentiality.
All testing for HIV and other communicable diseases is confidential. If you test positive, however, this information will be shared with public health, and your needle-sharing or sexual partners must be informed that they have been exposed to the disease. You will have a chance to ask any questions you may have about this when you are tested.
Make a point of discussing the limits of confidentiality with your doctor or counsellor early in treatment. This is especially important if you have children. When children are involved, your right to confidentiality may be waived if the children are deemed to be "at risk." This term is open to some individual interpretation. Some treatment providers may think that any evidence of illicit drug use puts children at risk. You'll feel a lot more comfortable if you understand your treatment providers' definition of the term.
As mentioned earlier, all methadone clients are registered with the Methadone Registry of the College of Physicians and Surgeons of Ontario (CPSO). This information is available to no one other than a methadone-prescribing doctor, and is kept only to ensure that no one receives treatment from more than one doctor. The only information collected is your name, date of birth, gender, health card number, city of residence when entering treatment, and who you are receiving treatment from (name of doctor and/or associated clinic). If you change treatment providers, or if you leave treatment, you will be asked to sign a form that allows the CPSO to change the information about you in their database.
A Patient's Guide — Avoiding Overdose in the First Two Weeks of Methadone Treatment*
Methadone is a very safe drug, but accidental overdoses sometimes happen in the first two weeks of treatment. The questions and answers below will help you get through this period safely. Share this information sheet with a friend or family member.
Why can't my doctor increase my dose more quickly?
When you first start methadone, you want to get on the right dose as soon as possible. But your doctor has to increase your dose slowly over several weeks, because your body takes time to adjust to methadone, and (unlike other narcotics), methadone builds up slowly in your bloodstream over several days. A dose that may feel like too little on a Monday could put you in hospital by Thursday.
What can I take to relieve withdrawal and help me sleep until the methadone begins to work?
Only take medications that are prescribed by your methadone doctor. If you're on a medication prescribed by another doctor, your methadone doctor needs to approve it because it could interact with methadone. Substances that make you relaxed or sleepy can be dangerous. This includes alcohol, opioids, benzodiazepines (Ativan, Valium, Rivotril, etc.), antihistamines such as Gravol or Benadryl, and certain types of antidepressants and tranquilizers. Even certain antibiotics can be dangerous, by blocking the breakdown of methadone in the body. So make sure to check all medications with your methadone physician.
Isn't methadone supposed to make you sleepy?
No. You are supposed to feel normal on methadone, not high or sleepy. Methadone builds up so slowly that someone can feel a bit sleepy during the day, lie down for a nap and not wake up. So please take the following precautions:
- Only take your methadone in the morning.
- See your doctor twice a week for the first two weeks.
- Discuss your methadone treatment with a close friend or family member. If they see that you're drowsy, they must call your methadone doctor or an ambulance.
What are some of the symptoms if my methadone dose is too high?
- You may feel sleepy, and nod off several times during the day.
- You may be forgetful.
- You may be difficult to wake up from your sleep.
- You may experience slurred speech, stumbling walk, or appear drunk.
If these things are occurring you must call your doctor immediately or go to Emergency as you may be overdosing.
I've been offered a small amount of methadone by a methadone patient at the pharmacy. This can't hurt — I know I need 80 mg!
Above all, don't take any extra methadone. It's probably safe for your friend, but could be lethal for you. You took 80 mg once and were okay. If you had taken 80 mg every day for three or four days, you might have died. Remember, it takes five days for a certain dose to build up in your blood.
*Reproduced with permission from Methadone Maintenance Guidelines, November 2005. Copyright 2005, The College of Physicians and Surgeons of Ontario.