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Doctor's Column

Thanks to all of these fine doctors for participating . . .

Our Medical Advisory Board includes Dr. Vincent Dole, Rockefeller University; Dr. Marc Shinderman, Director/Owner of Center for Addictive Problems (CAP) in Chicago; Herman Joseph, Ph. D., Research Scientist for the New York State Office of Alcoholism and Substance Abuse Services; Dr. Charles Schuster, Director of the University Psychiatric Center (UPC) and former head of NIDA, and his associate, Dr. John Hopper, Medical Director of UPC; and Dr. Andrew Byrne, Australia, who has written two books about methadone.

If you have any questions you need answered by the doctors about methadone, here is the place to send them. yourtype@tir.com    However, please read this first, or your question may not be answered.

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Should You Tell Your Dentist You Are Taking Methadone? - September 1999, Vol IV, No. IX

 Different Formulations of Methadone- August 1999, Vol. IV, No. VIII
 

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 Different Formulations of Methadone


Dear Doctor:

 Many patients have varying side effects and/or "feel" different formulations of methadone differently (e.g.:  clear liquid methadone, cherry methadose, wafers, etc.); some patients say one kind will "hold" longer than another, or one is "better" than another.  What is your opinion/experience with this?  Does your clinic offer patients a choice as to what formulations the prefer?  - Donna B.

Dear Donna:

 We offer the orange Disket ®, white 5 and 10 mg. Tablets, clear liquid and OrLAAM [Note:  OrLAAM is not methadone, it is another medication, with somewhat similar properties to methadone, used for maintenance therapy].  We have tried flavored liquids, but the patients did not like them.  I do not obsess about why patients prefer one thing or another.  We just try to make treatment as desirable as possible.

Marc Shinderman, M.D.
Center for Addictive Problems (CAP)
Chicago, Illinois
=============

Dear Donna:

 There are always some patients who cannot tolerate certain formulations so alternatives should be available.  Just as children sometimes need a 'spoonful of sugar', so adults also need to have a preparation which is tolerable.  All formulations of methadone that I have heard of taste disgusting.  Some people are driven to vomit just from the smell!  We offer an alternative to the usual gluggy syrup as a pure solution without sugar, preservatives, alcohol, coloring or flavoring.  About 10% of our patients cannot tolerate the usual solution and about half of these are happy with the pure solution (methadone powder dissolves easily in water).   Tablets are not permitted by most State laws and are not feasible for doses over about 50mg anyway.  Our average is now 90mg and maximum 400mg.

 The more formulations we offer, the greater the patient acceptability and the higher the retention rates will be.  Some side effects are due to the formulation while others may be due to the methadone itself.  Hence in a perfect world we need to offer LAAM, buprenorphine, long acting morphine or other drugs for difficult cases.  Some would even add prescribed heroin to the list as happens now in Switzerland.

 I hope this information is useful.

--Dr. Andrew Byrne
  General Practitioner, Drug and Alcohol,  NSW, Australia
 
 

 The Following are some common formulations of methadone:

 Methadone powder (to be mixed with water), white tablets (5 mg and 10 mg, also 40 mg), orange Diskettes (40 mg), cherry or other-flavored methadose, and clear liquid methadone. Another patient wrote in to our "Dear Doctor" column asking about a "methadone patch"; we're waiting for the responses from our physicians and will print the information in a future issue.
 

Editor's Note: Regarding different formulations of methadone, the following quote is from the federal regulations  -- FDA Regulations, §291.505, under (6)(iii) Form:

 "Methadone may be administered or dispensed in oral form only when used in a treatment program. Hospitalized patients under care for a medical or surgical condition are permitted to receive methadone in parenteral form when the attending physician judges it advisable. Although tablet, syrup concentrate, or other formulations may be distributed to the program, all oral medication is required to be administered or dispensed in a liquid formulation. The oral dosage form is required to be formulated in such a way as to reduce its potential for parenteral abuse. Take-home medication is required to be labeled with the treatment center's name, address, and telephone number and must be packaged in special packaging as required by 16 CFR 1700.14 in accordance with the Poison Prevention Packaging Act . . .to reduce the chances of accidental ingestion. Exceptions may be granted when these provisions conflict with State law with regard to the administering or dispensing of drugs."

 Be aware that regulations may differ State to State. For example, the following is written in Michigan's state regs:

Under R325.14415, Take-home medication, 415(1):

 "Take-home medication shall be formulated in such a way as to minimize parenteral abuse and shall be packaged pursuant to section 3 of the poison prevention packaging act, 15 U.S.C. §1472."
 

 Under R325.14416, Take-home methadone, 416(1):

 "...take-home methadone shall only be dispensed in an oral, liquid form so as to minimize its potential for abuse."
 

And, in 416(2):

 "It is recommended practice that this liquid vehicle be non-sweetened and contain a preservative so that a client can be instructed to keep take-home methadone out of the refrigerator in an attempt to minimize the likelihood of accidental overdoses by children and fermentation of the vehicle.
 


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Should You Tell Your Dentist You Are Taking Methadone?

Dear Doctor:
 
 I'd like to know if you think it's absolutely necessary to tell a dentist or oral surgeon that a patient is on methadone.  In my experience over the years, I find the doctor AND dentists are super reluctant to give me any kind of pain medication once I've told them I'm a methadone patient.  I plan on going to a new dentist, and I don't see any reason to tell this lady about the methadone, do you?    -MG
 

Dear MG:
 
 The FDA consent to treatment specifies that you inform health care providers of your being on methadone/LAAM.  Ultimately, the responsibility and timing for notifying the provider rests with you.  I think notification is critically important if you are going to receive any medications or prescriptions from this provider.  If you are asked to list your medications, you are protecting yourself from potential injury by letting the provider know about your methadone/LAAM treatment.
 
- John Hopper, M.D.
University Psychiatric Center
================
 
Dear MG:
 
 In a perfect world you would always tell your dentist that you took methadone.  I can understand some not doing so in the current climate of prejudice against dependent patients, some of whom have never used heroin in their lives, but are dependent on other opioids.  The emergency ward is another place where a methadone history can cause a change in attitude of ignorant staff.

 If there is any chance of the dentist or doctor giving "systemic" drugs (e.g. tablets or injections but not "local" anesthetics) then you should certainly reveal your other medications, including methadone.  Certain pain killers contain partial opioid antagonists—pentazocine is an example—and these will cause immediate severe withdrawals in patients on methadone.

 So you have to make another balanced decision, as elsewhere in life.  Do you risk the potential problems knowing that there may also be adverse consequences in revealing that you are on methadone?
 I hope this information is helpful.
 
Dr. Andrew Byrne,
General Practitioner, Drugs and Alcohol,
New South Wales, Australia
 

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