PRESCRIBING METHADONE FOR
PAIN
By: David J. Wilmont,
M.D.
Of all the strong narcotic analgesics
in our formulary used to treat severe or intractable pain, methadone
(Dolophine, Lilly) is surrounded by a mystique perhaps greater than any other
agonist medication available for use legally. Unlike other powerful opiates or
opioids, like meperidine (Demerol,) morphine sulfate, fentanyl (Duragesic
transdermal system,) oxycodone (Percocet, Percodan, OxyContin) or hydromorphone
(Dilaudid,) methadone has been singled out as the only acceptable opioid for use
in detoxification from narcotic addiction. Methadone is also the only
narcotic approved in the United States for use in maintenance programs designed
to treat opiate or opioid dependent individuals. Within these programs, most
often heroin (or other narcotic) addicts are given single daily dosages of a
form of methadone called Methadose. The purpose here is to prevent the
addict from going through a withdrawal or abstinence syndrome upon cessation of
use of his or her narcotic drug of preference. This is done in federally
licensed NTP's (or Narcotic Treatment Programs) located virtually everywhere in
the nation.
Like it or not, accept it or not, a
powerful stigma has been attached to methadone as a result of its status as the
only legally approved drug for management of opiate and/or opioid
addiction. Methadone also happens to be a superb and most efficacious
medication for treatment of intractable pain. And here is where a
figurative line begins to blur. It is a commonly accepted fact that
different people respond differently to one medication over another, despite the
fact that two or more drugs may be generally regarded as effective analgesics
for use in cancer or other severe pain which presents as difficult to
control. Hence, it should be no surprise that for some, no drug is
superior to methadone in medication resistant cases of pain
management.
Only a few years ago, private practice
physicians were either outright prohibited, or simply discouraged from
prescribing methadone in the course of their medical practice for the purpose of
managing or relieving pain and associated suffering within their patients so
unfortunate as to be plagued with this horrific malady. Laws in this
regard varied from state-to-state, further complicating the issue. And doctors
had no real choice but to order some "second best" medication for
these patients. It would be impossible now to calculate or even estimate just
how much needless suffering resulted from the presence and enforcement of these
laws, delineated to "protect" us.
Today, circumstances have changed,
although to what degree remains a matter of much discord and debate. It is
now legal throughout the United States for any licensed medical doctor to
prescribe methadone for any patient deemed to require it. However,
the system which governs this prescribing is still replete with
complexities. For example, let us cite, in everyday language, the plethora
of requirements faced by a General Practitioner devoted to providing comfort and
increased quality of life for a patient suffering with severe pain. Our mythic
patient in this context clearly responds best to methadone; not at all an
unusual factor, rather one routinely encountered in pain management. Our doctor
must, as a precursor to treatment, begin by demonstrating, in writing, why
methadone would be preferable to any other very potent narcotic
agonist. By its very nature, this is a volatile declaration,
extremely vulnerable to debate. So in order for our physician to undertake
his preferred course of therapy, he or she must be well prepared to defend this
decision should some highly zealous drug enforcement personnel elect to
vehemently disagree. This is the sort of thing
that can cause a license to practice medicine to be suspended or revoked. Or at
the least, it can be a position phenomenally expensive to defend. In all
likelihood, the best evidence our practitioner will have that methadone indeed
should be used as opposed to another strong opiate
will be, quite singularly, the testimonial of the suffering
patient.
One "brighter side," albeit
to a geographically-dependent, potentially dim side as well -- is the advent of
medical operations devoted exclusively to the practice of pain management.
This can mean "problem solved" for patients living in large
metropolitan areas. Ah, but if you suffer with severe pain (and most
assuredly if it's from a cause other than cancer, the whole
nightmare begins anew for those in rural areas.
So what is the promulgating factor, the
driving force behind this didactic governmental edict? The primary concern
of the Drug Enforcement Administration with regard to methadone is
diversion -- e.g. large scale, illegal
reappropriation of supplies from legitimate channels to the black market.
This whole-hearted bureaucratic mindset emerges not because there truly exists a
large, great and danger-ridden diversion issue with methadone. In truth
and conversely, methadone is not the hyperfocal supertarget of misuse many would
have you believe. Because methadone blocks, at opiate receptors in the
brain, other narcotics from being even close to fully and normally effective was
in great part the reason it was chosen as the detox and maintenance drug of
choice. For this very same reason, seasoned narcotic addicts do not
particularly care for it. Certainly methadone can and is a drug subject to
misuse, and its control status on Schedule II is appropriate. However, for
purposes akin to "getting high," devoted druggies would quickly and
readily cleave onto virtually any other very potent
narcotic pursuant to the realization of that endeavor.
The remaining question? Whom,
just exactly whom is left to most likely suffer from the benefits of laws
governing the use and distribution of methadone? If you're a severe pain
sufferer who obtains superior analgesic effects from methadone, you
are.