Question about residential drug rehab standard of care
March 19, 2017 5:29 PM   Subscribe

Wanting to understand the current standard of care for residential drug rehab, detox, and methadone. Is it standard of care to detox someone off of methadone?

Someone I know is in residential drug rehab for 60 days. For reasons, I participated in finding the rehab place (making me feel somewhat responsible hence this question). For background if it's relevant: the person has a longtime opiate addiction (mostly pills and some heroin), plus heavy use of alcohol and meth. The person also has a methadone scrip and was using methadone in addition to the illegal substances.

Here's my question: I assumed that the "standard of care" for heavy opiate addiction was MAT e.g. methadone, suboxone, etc. But I learned yesterday (I am double checking tomorrow), that the detox is including methadone. In other words, the person is being detoxed from everything including methadone. The rehab place is not "anti-medication" for other purposes -- in fact it focuses on dual diagnosis (part of the reason for selecting) and the person is being assessed for anti-depressants.

Is this -- detoxing off everything including prescribed methadone -- consistent with the standard of care? Is it case by case? Does it depend on the facility? What does the medical literature say?
posted by ClaudiaCenter to Health & Fitness (8 answers total)
It depends on the facility. There are some facilities that don't do "detox" for opiate dependence, because as awful as opiate withdrawal feels, it won't seriously harm a person. Putting people on methadone or suboxone is done outpatient and particularly doesn't require an inpatient detox because, well, you're not going to experience withdrawal symptoms if you're taking methadone or suboxone, which is the whole point of those meds.
posted by treehorn+bunny at 5:43 PM on March 19 [1 favorite]

Unfortunately, there is no standard of care and the majority of substance treatment programs do not conform to available evidence.

Perhaps this will work out for your friend. Some abstinence based programs will work for some people. I've seen it happen.

Methadone is supported by evidence, more than abstinence.

In California some of this will change as "drug MediCal" rolls out and funding becomes more linked to evidence.
posted by latkes at 5:46 PM on March 19 [3 favorites]

I should add that there is good evidence that methadone and suboxone do work (here's just one of many available reviews on the subject), better than abstinence. That being said, it is a tough thing because if someone is abusing methadone, that's extremely dangerous, and also I do get frustrated with methadone treatment centers because at least the one whose patients I mostly work with never dials down the dose, and I don't understand why folks are still on a huge dose of methadone 20 years after starting methadone maintenance, although it's certainly better than being dead or on heroin.
posted by treehorn+bunny at 5:48 PM on March 19 [3 favorites]

I know this isn't your question but it sounds like the person in question might be trying to make you feel bad for helping them seek help. Please don't feel bad for helping save this person's life.
posted by treehorn+bunny at 5:51 PM on March 19 [5 favorites]

Thanks, all. Just trying to decide if I should leave it be or call the facility to ask some pointed questions. Or if it's so dramatically bad in the world of drug treatment that there should be consideration of a different facility (which seems like a last resort kind of option given the amount of tribulation that would require). I don't want to interfere but I want the person to have appropriate care. But I don't really have much expertise in this area. (For example, I don't know if it is relevant that the person previously had outpatient methadone services and later experienced a more severe addiction problem -- or which way that cuts.) I'll probably start with a call and some questions. I may not even have all of the information.
posted by ClaudiaCenter at 6:45 PM on March 19

You should definitely be calling and asking some pointed questions. Methadone is the gold standard for opiate dependence and taking someone off of it increases their risk of a number of bad consequences. The only reason I would accept for a methadone detox would be because they would like to switch to suboxone instead. It would be a huge, enormous red flag for me and I would have a lot of questions. They should be stabilizing the dose of methadone, not taking them off it. Feel free to message me if you want.
posted by gingerbeer at 8:05 PM on March 19 [2 favorites]

Yeah, this is hard and complicated stuff. I have a strong personal dislike for methadone: my experience is the quality of 'counseling' they provide is poor, and methadone is in a sense 'more addicting' than heroin in that the withdrawal is worse. Lots and lots of people use both methadone and heroin at once or cycle endlessly through "21 day detox" methadone programs. Or they stay dependent on methadone for life (see below for more on that). Bupenorphine and Suboxone are relatively new and while there is promising evidence for their use, it's not magic and I personally want to give some more time before I get too excited about it.

Having said that, medication assisted treatment absolutely saves lives: the evidence is consistent and strong and much stronger than for 12 steps or other abstinence based programs. And lots of experts now say that opiate dependent people have changes to their brain structure that means that perhaps they do need to be on some kind of opiate replacement for life. A few places actually prescribe medical-grade heroin in a safe setting for long time addicts.

The whole concept of "detox" is medically specious in my book and the strong preference for complete abstinence is very common and very problematic. Here in the East Bay where I live, I know of few programs that support MAT - most are abstinence based. That doesn't mean it's right, but it's what I've seen.

Check out the writing of Maia Szalavitz, (metafilter user Maias) who does very accessible popular journalism about addiction and treatment.

If this was my friend, I might just see what happens honestly. Maybe this program will click for this person. I'm not sure that your strongly-worded phone call is likely to help. Having said that, cumulative feedback along with a change in general social policies will surely help shift these programs over time.

That's just my personal two cents, not trying to contradict you or gingerbeer or anyone.
posted by latkes at 8:19 PM on March 19 [2 favorites]

Just spoke with the person directly -- they state that they will continue in the program and are now in support "getting off everything." (Previously they and I thought maintenance methadone was appropriate.) I let them know that methadone is an option now and in the future. I guess this was a life lesson for me. Don't ASS-U-ME. I never even asked about the details of detox -- we were in such a hurry / panic to find a place. I probably wouldn't have picked it had I known. In good news, the person sounded great on the phone.
posted by ClaudiaCenter at 11:12 AM on March 20 [2 favorites]

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