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Journal of Nursing

Barriers to Patients Undergoing Methadone Maintenance Therapy

Ashley Giordano, Lindsay Harrington, Courtney Letourneau, Laura Smith, & Sara Vermouth [email protected]


Nationwide the usage of opiates has risen, with drug overdose being the leading cause of death by injury in 2011 (Centers for Disease Control and Prevention, 2014). This surge in opioid drug use demands greater attention to the treatment of opioid addiction. Methadone maintenance therapy has been shown to be an effective treatment for opioid addiction and is a method of addressing the growing need for intervention (Bonhomme, Shim, Gooden, Tyus & Rust, 2012).

Methadone Maintenance Therapy


Methadone maintenance therapy (MMT) is a proven method for the treatment of opioid addiction (Bonhomme, Shim, Gooden, Tyus, & Rust, 2012). To be a candidate for MMT, a patient must have a one year history of addiction to a substance and voluntarily choose MMT. There are no limits on the duration or the dosage level of medication, unless clinically indicated. It is also required that patients receive substance abuse counseling (psychological treatment) in combination with prescribed methadone (Substance Abuse and Mental Health Services Administrations, 2013). This combination of pharmacological and psychological treatment should be reviewed initially and periodically throughout treatment, including eight random drug screenings annually for benzodiazepines, barbiturates, and alcohol (Substance Abuse and Mental Health Services Administrations, 2013). Furthermore, counselors and clinicians who are specifically trained to identify symptoms of withdrawal and adequacy of dose should consult with the medical staff for greater integration of care, which may improve treatment outcomes. A comprehensive patient history regarding medication and drug use is also crucial in identifying potentially hazardous interactions with methadone (Baxter et.al, 2013).

Understanding methadone and its mechanism of action can help providers understand MMT as a treatment modality. Methadone, heroin, and other opioid derivatives act upon the same opiate receptor sites in the brain; however, the most clinically significant receptor is the mu receptor (Veilleux, Colvin, Anderson, York & Heinz, 2010). Methadone has a higher affinity to these receptor sites, and therefore, acts as a blocking agent to other opioid derivatives. The ability for methadone to block the effects of other opioids such as heroin, allows for a reduction in withdrawal symptoms, cravings, and the euphoric effect of opioids (National Institutes of Health, 2010). In addition, methadone has a longer duration of action than other opioids, which enables patients to be stabilized for an extended period of time (National Institute on Drug Abuse, 2012). Many former heroin users treated with oral methadone show virtually no overt behavioral effects of treatment with methadone (Mattick, Breen, & Davoli, 2009).

Similar to other opiates, methadone usage produces cross-tolerance and dependence, which is a crucial concept to understand when treating patients undergoing MMT (Brunton, Chabner, & Knollman, 2011). It is not uncommon for MMT participants to be under-medicated for acute pain because providers have misconceptions and stigma surrounding the therapy. Oliver et al. (2012) stated care for patients undergoing MMT and requiring pain management may include:

1. Confirming the methadone dose and compliance with MMT provider.
2. Continuing the methadone dose without relying on the dose for analgesia.
3. Maximizing the use of non-pharmacological interventions to treat pain.
4. Administering larger than recommended doses of pain medication due to opioid tolerance
.
The under treatment of pain in methadone patients can result in anxiety and stress. These two factors are more likely to contribute to patient relapse than the usage of opioid analgesics for pain management. Addressing misconceptions and knowing the facts about methadone may lift the stigma associated with MMT.

Barriers to Treatment


A significant issue associated with treatment failure of participants is the negative stigma radiating from the medical community. In a review of the literature, van Boekel, Brouwers, van Weeghel and Garretsen (2013) found that there is an overall negative view of patients with a history of substance use disorder. This stigma is so profound that it prevents patients with mental health disorders, including substance abuse disorders, from seeking care (Langille, 2014). Factors contributing to this negative view may include the lack of adequate education and training with substance abuse patients amongst healthcare professionals. Van Bockel et. al. (2013) found healthcare professionals demonstrated diagnostic overshadowing involving a lack of attention to illness symptoms and diminished communication. In addition, healthcare providers have historically approached this population in a task-oriented manner, while minimizing personal engagement, empowerment, and collaboration between the provider and the client (van Boekel et al., 2013). Stigma may hinder participants’ self-esteem, and inhibit the completion or continuation of treatment. Stigma also has profound effects on families of those with substance abuse disorders (Langille, 2104).

Overcoming Barriers to Treatment


Substance abuse continues to be a national problem, with methadone maintenance being one of the proven treatment options for patients. Research findings suggest that many healthcare professionals have an overarching negative view of people with substance abuse disorders, including patients undergoing methadone maintenance therapy. Educated providers may remedy the stigma felt by patients. In their literature review, van Boekel et al. (2013), found positive effects of training and education on the views and perceptions of substance use disorders by healthcare professionals. The authors established a recommendation for health services and educational institutions to incorporate more specific education and training regarding MMT in their curriculum (van Boekel et al., 2013). Another educational approach involves recovery-oriented, contact-based education. With this approach, people involved in MMT talk about their experiences in live presentations or videos (Langille, 2014).

Conclusion


Healthcare professionals need a comprehensive understanding of methadone treatment to provide competent care for MMT patients, and to empower patients to seek treatment. Through education, healthcare providers can work towards decreasing the stigma experienced by patients on methadone maintenance. Discussion of the mechanism of action and the requirements of methadone programs can help providers plan care for these patients.



References


Baxter Sr, L. E., Campbell, A., DeShields, M., Levounis, P., Martin, J. A., McNicholas, L., ... & Wilford, B. B. (2013). Safe methadone induction and stabilization: report of an expert panel. Journal of addiction medicine, 7(6), 377-386.

Bonhomme, J., Shim, R.S., Gooden, R., Tyus, D., Rust, G. (2012). Opioid addiction and abuse in primary care practice: A comparison of methadone and buprenorphine as treatment options. Journal of the National Medical Association. 104, 342-350.

Brunton, L., Chabner, B., & Knollman, B. (2011). Goodman & Gilman's the pharmacological basis of therapeutics (12th ed.). New York: McGraw Hill.

Center For Disease Control and Prevention. (2014). Prescription drug overdose in the United States: Fact sheet. Retrieved from http://www.cdc.gov/homeandrecreationalsafety/overdose/facts.html.

Langille, J. (2014). Reducing stigma in health-care settings. Canadian Nurse, 10(1), 35-36.
Mattick, R.P., Breen, C., Kimber, & J, Davoli, M. (2009). Methadone maintenance therapy versus no opioid replacement therapy for opioid dependence. Cochrane Database of Systematic Reviews, 3, (CD002209). Doi: 10.1002/14651858.CD002209.pub2

National Institute on Drug Abuse. (2012). Principles of drug addiction treatment: A research-based guide. Retrieved from http://www.drugabuse.gov/publications/principles-drug-addiction-treatment-research-based-guide-third-edition/frequently-asked-questions/use-medications-methadone-buprenorphine.

National Institutes of Health. (2010). The brain: Database, heroin addiction. Retrieved from http://www.science.education.nih.gov/supplements/nih2/addiction/activities/lesson5_database-heroin.htm.
Oliver, J., Coggins, C., Compton, P., Hagan, S., Matteliano, D., Stanton, M., ... & Turner, H. N. (2012). American Society for Pain Management Nursing position statement: Pain management in patients with substance use disorders. Pain Management Nursing, 13(3), 169-183.

Substance Abuse and Mental Health Services Administrations. (2013). Federal guidelines for
opioid treatment. Retrieved from http://www.dpt.samhsa.gov/pdf/FederalGuidelinesforOpioidTreatment5-6-2013revisiondraft_508.pdf.

van Boekel, L.C., Brouwers, E.P., van Weeghel, J., & Garretsen, H.F. (2013). Stigma among
health professionals towards patients with substance use disorders and its consequences for health care delivery: Systematic review. Drug and Alcohol Dependence. 131(1-2), 23-35.

Veilleux, J.C., Colvin P. J., Anderson, J., York, J.C., &. Heinz, A.J. (2010). A review of opioid
dependence treatment: pharmacological and psychosocial interventions to treat opioid addictions. Clinical Psychology Review. 30(2), 155-166.

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