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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.
To subscribe to the newsletter: 
Dr. Column 3/97-9/97 / Dr. Column 10/97-3/98
/ Dr. Column 4/98-10/98
Dr. Column 11/98-7/99
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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