Addiction & Psychotherapy Services

2824 S. Congress Avenue, Austin, TX  78704  |  (512) 444-5092

Patient Information Booklet

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Contents

1. Basic information
          - Indications for treatment
          - Risks/benefits of res & outpt med withdrawal vs. maintenance
          - Intake/Initial evaluation
          - Treatment; Basic understanding of needs and agreements
          - Confidentiality
          - Basic information about methadone treatment
2. Basic expectations of patients
          - Attendance
          - Fees
          - Appointments
          - Urine drug screening
          - Group attendance
          - Other treatment
3. Expectations regarding patient behavior
          - Parking Lot
          - Contact with other clients
          - Miscellaneous
4. Special Requests (dosage adjusts, refills, extra take homes)
5. Take home methadone, lock boxes & safe handling/storing of doses
6. Inappropriate and illicit behaviors of patients
7. Information for methadone patients (per JCAHO regulations)
          - Addictions course, particularly opiate addiction treatment alternatives.
          - Summary of confidentiality policies and regulations
          - Infectious diseases of addiction, and ways to avoid infection
8. General recommendations for all clients
9. Frequently asked questions


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1. BASIC INFORMATION

Indications for Treatment

All patients with opiate addiction, including heroin (snorted, smoked or injected), pain pills, or injected pain medications may be appropriate for treatment. Addiction usually means daily use or use several times daily of at least one month duration, with major problems associated with that use. Patients are usually aware they have a problem but seem unable to stop using the drug. In therapeutic use of opiate/opioid medication, the patient functions well because of the medication, while in addiction, drug seeking and the effect of the drug interfere with good functioning. Patients usually use the drug for many reasons, including physical and mental discomfort, boredom, or to celebrate. They think about drug use or fear withdrawal most of the time. When used for chronic pain, patients often become dependent on an opiate dosage much larger than seems justified by the medical condition, and often show signs of psychological addiction. Psychological addiction implies the presence of craving to use the medication for many reasons other than severe pain.

Pregnant women with a history of addiction or currently abusing opiate drugs should be evaluated and possibly admitted to methadone maintenance treatment.

Former opiate-addicted individuals who were recently discharged from residential treatment or penal institutions, and former patients who recently discontinued methadone maintenance treatment may qualify for admission without being currently physiologically dependent to opiates.

The Risks/Benefits of Residential and Outpatient Medical Withdrawal vs. Maintenance Treatment

Most individuals in danger of relapse do much better in outpatient methadone treatment than in short-term residential treatment or rapid medical outpatient withdrawal. Relapse rates are high for individuals leaving short-term treatment, and repeated relapses can become dangerous. However, patients with severe abuse of multiple medications (opiates, alcohol, tranquilizers, cocaine and cigarettes) may benefit from inpatient detoxification, even if follow-up treatment includes methadone maintenance. All patients need long-term psychosocial treatment, and many patients also need psychiatric treatment, as offered at this clinic.

Intake and Initial Evaluation

Before starting an intake, patients interested in treatment must read and sign an Informed Consent form and the Financial Responsibility Agreement.

The initial evaluation consists of a health and substance abuse history, physical examination and psychosocial evaluation. The purpose of the evaluation is to determine what treatment is indicated in accordance with federal and state regulations. There is no guarantee that the applicant will be admitted for treatment.

Before starting methadone treatment, it must be established that an individual is actually addicted to opiates. A urine specimen will be obtained for drug screening and health screening purposes. In special cases, a narcane challenge test may be needed. Narcane 0.3-0.5ml (120-200mg) is injected i.m. The medication counteracts opiates in the body inducing symptoms of withdrawal. As soon as symptoms occur, appropriate treatment will be started.

Regulations require that an RPR (syphyllis test) be obtained within the first 14 days of treatment. The clinic will send you to a nearby lab where a blood and urine specimen will be obtained. These samples are used for health purposes only,  and the lab fee is included as part of your intake fee.  No additional payment is needed at the lab. If the lab work is not obtained in the first 14 days of treatment, an administrative withdrawal will begin and your methadone dose will be tapered down.

Patients may revoke part or all of their consent at any time except to the extent that action based on the consent was already taken and/or the consent is a condition of present treatment.

Treatment -- Basic Understanding of Needs and Agreements

Treatment applicants must understand that abuse/addiction is a progressive disorder that requires long-term treatment. Early withdrawal almost always leads to relapse. The main goals of treatment are stability with opioid medication maintenance along with psychological treatments, abstinence from illicit drugs, alcohol and nicotine, and dealing with the problems that led to or were caused by substance abuse/addiction. If admitted, the client must commit to staying in treatment for at least four to six months, to regularly attend educational groups and individual sessions, and to cooperate with the individual treatment plan as developed by the patient and his/her case manager. Basic treatment includes methadone maintenance or slow medical withdrawal (over six months), as well as group and individual teaching and counseling. The treatment plan may also include specific groups, life style changes, couples therapy, use of antidepressant medications and referrals to other health care providers.

Treatment may include acupuncture by trained staff. Acupuncture consists in the insertion of very fine disposable needles into the skin at indicated places (ear). Although well established, the procedure is considered investigational. There may be slight discomfort. Acupuncture is generally effective in alleviating withdrawal symptoms, craving and stress symptoms. Acupuncture is safe. There is little to no danger of significant pain, significant bleeding, fainting, or local infection.

Patients must affirm that they have read and understand the fees of this clinic and patients must affirm that they have the financial resources or support to afford long-term private outpatient treatment. They must accept full responsibility for the payments of fees at the time the fees are due. The clinic does not bill patients and does not file insurance claims (for filing, required forms are available on request).

Confidentiality

The information given by the client is confidential and the clinic staff is not allowed to give any information regarding evaluation, history and treatment to anybody outside this clinic, unless the patient signs a specific consent to release information. Without written consent, staff cannot answer questions whether a person is, was, is not or never was a client of this clinic. Auditors have the right to review charts and/or talk to patients but are also bound by confidentiality rules. Exceptions from confidentiality regulations include: medical emergencies, or if there is a valid subpoena. In addition, we also must report suspected child or elder abuse.

Basic Information Regarding Methadone/Suboxone (buprenorphine) Treatment

Pharmacology and side effects of methadone, heroin and other opioids are similar, except that methadone and Suboxone are taken by mouth, are absorbed slowly and last much longer than injected heroin or pain pills. When taking these medications, patients will not get a "rush" or "high" as with heroin. The patient will feel “normal,” (as if he/she had taken heroin several hours ago). If methadone treatment is interrupted, the medication leaves the body slowly. Methadone withdrawal is much milder but lasts three to four times longer than heroin withdrawal. (Withdrawal can be much shortened and intensified by use of the narcotic antagonist medications narcane or naltrexone [Revea].)

 

2. BASIC EXPECTATIONS OF PATIENTS

Attendance

Patients are expected to attend the clinic for methadone according to their current attendance schedule. Appointments are required per the clinic's regulations and should be kept by the patient. Attendance is also strongly urged for counseling and educational groups.

Fees

After paying for intake ($120 for methadone or $150 for buprenorphine (Subutex) cash or money order; see ‘Fees’ section of http://www.austinmethadone.com), a patient may make the first weekly payment later that week or, at latest, before dosing on Monday. Patients may make several partial payments (e.g. $5 to $10 every day), but fees are expected to be completely paid up by Monday. Payment may be made in advance for several weeks. This clinic works with no profits and charges very low fees while offering highest quality services. As treatment makes normal functioning possible, we expect patients to make their fee payments a first priority. If a patient has difficulties making payments and has been in treatment for at least three months, he/she may fill in a fee consideration request form prior to noon on Tuesday of the week prior to needing consideration. It is also advisable for the patient to consult with his or her counselor. If the full amount cannot be paid by Monday of the week due, we advise the patient pay as much as possible and that the balance be paid within a few days. Non-payment leads to reduced dosage and medical withdrawal.

Appointments

Counseling and treatment plan appointments:  A client should make appointments with his or her case manager at the beginning of treatment at least weekly until the client feels well adjusted. Appointments every three to six weeks are recommended, or if stable, at least every three months. Client should talk with their case manager about important changes in life, stress, health issues, or any concerns the client wishes to address. The case manager may suggest an appointment with the physician-psychiatrist if appropriate. Generally, questions about treatment of sleep disturbance, nightmares, head aches, anxiety, stress, lack of energy, depression, back pain, stopping smoking, etc. should be brought up first in the "Ask the Doctor" group. If it appears indicated and after consulting with the case manager, the client may make an appointment with the psychiatrist.

Missed appointments:  If an appointment is missed with a counselor, nurse, or the physician without canceling a day in advance, the patient will be charged $10.

Urine Drug Screening

Patients are expected to give urine specimens when randomly requested any time they come to the clinic for medication. Not giving a specimen for any reason must be counted as refusal and is considered an indication of instability. It impacts earning or maintaining take home privileges. If there are difficulties giving a urine specimen, a client may stay and drink water, but they must not leave the clinic -- even to go to the car. If a client leaves and returns, the urine specimen cannot be accepted as random.

A patient must never alter a specimen, that is, never add another substance or water to it. If there are questions regarding a patient's honesty, he/she may be observed by staff while giving the specimen.  Falsification of a urine specimen is considered a significant sign of poor judgment and will invariably lead to a reduction of take home privileges.

Group Attendance

New clients are expected to attend at least two educational groups monthly. Educational groups include "Positive Change", "Ask the Doctor", "Rx and Health", "Grief and Loss" or "Pain Management". We expect clients to attend at least four groups quarterly, and of these at least three should be educational. If a client has significant problems, more groups are advised. Group attendance is usually required to earn take home privileges or obtain fee considerations.  Current group schedules are available in the clinic lobby and the current schedule is also available on our website at http://www.austinmethadone.com

Most questions about treatment are appropriate for the "Ask the Doctor" group. In this group, clients may learn about many issues related to abuse and addiction, general mental health, sleep, general medical and pharmacological concerns and many self-help techniques. Participation is not required in any group. Clients are not expected to talk about personal matters. They may come and listen -- no one is expected to talk if they feel too shy. Close relatives and friends, including older teenagers, may attend groups with clients.

Other Treatment

Patients are expected to inform program staff of any medical or psychological treatment that they receive outside Addiction and Psychotherapy Services. They are expected to show all prescriptions to program staff and inform program staff of over-the-counter medication and herbal preparation use. In addition, patients should inform any other treating physician of his/her treatment at this clinic. If appropriate, clients are expected to sign a Consent to Release Information for clinic staff to communicate with physicians and/or therapists whom they see. Patients should understand that continued use of addicting pain medications, diet pills, stimulants, tranquilizers and sleeping medications (e.g., Darvon, Tylenol #3, Xanax, Valium) is inappropriate and often dangerous for patients in methadone or Suboxone treatment. Urine specimens containing such drugs may be considered positive for an illicit substance even if the patient has a prescription for the medication. Many drugs interact with methadone and Suboxone including certain antibiotics, seizure medications, and sleeping medications. Certain pain medications such as Talwin, Stadol, Nubain, Buprenex and Dalgan, as well as Revea lead to acute withdrawal.

 

3.  EXPECTATIONS REGARDING PATIENT BEHAVIOR

Parking Lot

Loitering:  It is expected that clients remain inside the clinic except for short smoke breaks. Any form of loitering outdoors, staying around the clinic, waiting for others and talking in the parking lot or on the sidewalk in front of the clinic, is considered suspicious behavior and is not allowed. We want to protect our clients from solicitations and offers to buy or sell drugs. In addition , we want to avoid old conflicts being dealt with on or close to the premises. Clients should not arrive at the clinic before 6:00am unless there is an urgent reason. If a client arrives before the clinic is open, we request the individual to stay in their car until the door is unlocked. 

Clients are not allowed to park or loiter in the parking lot of a neighboring business.

No parking is permitted in handicapped spaces unless a client is physically disabled and legally allowed to park there. (The handicapped spaces are in front of the front door.)

Contact with Other Clients

This clinic is not a place to make friends or to build a support system. This is in contrast to AA/NA meetings. We assume that most clients are vulnerable to relapse and that clients tend to decrease others' resolve rather than being able to help them with craving.

Miscellaneous

Missing methadone:   If a patient misses a methadone dose, there is no reason to panic. Significant withdrawal symptoms are not expected until several days later. Over-the counter medications such as Benadryl and ibuprofen may be helpful. We do not dispense methadone or order prescriptions while the clinic is closed. However, a telephone message (called to 444-5092) should be left as to why the patient is not able to attend. On return to the clinic, the patient should fill in an "Explanation for Missing Scheduled Day of Methadone Dosing" form.  If a methadone dose is missed after a patient has had a take home dosage, regulations require us to obtain a urine drug screen for which the patient is charged $10.

Out-of-hours dosing:   If it is not possible to attend the clinic during medication hours, a patient may get dosed out-of-hours during office hours (M-F until 1:30pm, however NOT on Tuesdays and Thursdays between 10:00am-12:00 noon), if and when a nurse is available at a fee of $10.

Early dosing:   Clients should not arrive at the clinic before 6:00am unless there is an urgent reason. If a client arrives before the clinic is open, we request the individual to stay in their car until the door is unlocked. If it is necessary to be dosed by 6:00am because of other obligations, the client may discuss the situation with his or her case manager. Clients who have a documented reason to leave the clinic very early are medicated ahead of other clients.

Common Courtesies:  We expect clients to be courteous, even if they strongly disagree with a statement or action of a staff member. Abusive and hostile language, threats, screaming or other aggressive behaviors are not acceptable.

We expect all clients and persons accompanying clients to be appropriately dressed. Men must wear shirts. Coming in without shoes is potentially dangerous -- as it is at any medical facility.

If a child is brought to the clinic, they must be closely supervised. The child must not be held while the client is dosed and if needed, clients should ask for help from staff to hold a child. Children must wear shoes and should never play on the floor.

Pets/animals are not allowed in the clinic and the clinic premises. Dogs and other pets must be left in the car (with windows partly open) while a client is medicated. Pets should not be left in the car during appointments or groups. Dog walking is not permitted on clinic grounds.

Weapons, illicit drugs and/or alcoholic beverages are not permitted in the clinic or its surroundings.

 

4.  SPECIAL REQUESTS (DOSAGE ADJUSTMENTS, REFILLS, EXTRAORDINARY TAKE HOMES)

If a dosage change is needed or travel is necessary, a client may fill in a "Dose Change Request Form" or "Take Home Request Form" and make an appointment with the case manager if necessary.  These forms can be found on the table in the lobby of the clinic.

While in methadone treatment, the patient may at any time request a dosage adjustment and slow medical withdrawal. Forms for dosage change requests are readily available. All areas of the form should be completed by the patient, after which it will be responded to as soon as feasible.

Special requests must be submitted a minimum of 24 hours in advance. The Medical Director is available for emergencies only on Fridays and Saturdays.  This means requests for a dose change or travel doses should be submitted no later than Thursday for a request taking effect on Monday. Refills on medications are NOT considered an emergency, and medications will NOT be refilled on Fridays and Saturdays.

5. TAKE HOME DOSAGES OF METHADONE AND SUBOXONE

Safe Handling and Storing of Take Home Doses

All patients receive take home dosages for Sundays and for certain holidays from the beginning of treatment. Only the patient is allowed to receive his/her take home dosages and the patient must agree to take full responsibility for their proper storage and handling. The patient must place take home dosage(s) into a locked metal container as soon as received. He/she must keep the medication in the locked box in a safe place. The patient must acknowledge that he/she is responsible for lost or stolen take home dosages and understands that the medication may be fatal to a person not addicted to opiates and/or on other medications. Methadone is particularly dangerous for children and intoxicated individuals. It is generally advisable for the client to place the lockbox into an inconspicuous shopping bag, large purse, brief case or backpack. Methadone must not be refrigerated and the refrigerator or ice chest is not a safe place to store it. Methadone should never be placed in a medicine cabinet or other location readily accessible to house guests. Patients are expected to transport and keep take home dosages in the lockbox and in a safe place AT ALL TIMES and especially out of the reach of children. It should not be left in a car that may get very hot and never placed in the back of an open pick-up.

Sharing a lock box is not allowed. Spouses or partners who also attend the clinic may not share a box. Each patient must have his/her own metal lock box in order to receive a take home dose. If a patient does not have an adequate lock box, no take home dose will be given.

Lost or stolen methadone cannot be replaced. The patient is expected to check the label when receiving it and to check that the lid is tightly closed.  It is the patient’s responsibility to drink take home dosages on the date indicated on the bottle. The take home dosages should be taken in order as labeled. If methadone is kept past the date indicated, or if a client's friend holds the methadone, it may be considered an illicit drug and the client and/or friend may be accused of having kept methadone for illicit sale. If a client forgot a take home dosage or felt they did not need it, it will be outdated. It should be disposed of promptly, or brought into the clinic the next day to be disposed of properly and documented by staff. 

At home, the locked lockbox must be kept in a safe place outside the reach of children.

When traveling, it is best if the methadone take home lockbox is kept with the client. It is advisable to take it into the cabin when traveling by bus or plane. If luggage with methadone is lost, dosages cannot be replaced and the client may possibly be liable if another individual takes the methadone and overdoses.  

6. INAPPROPRIATE AND ILLICIT BEHAVIORS BY PATIENTS

Patients and accompanying persons are expected to wear shoes and shirts. Children must be closely supervised by their parents or caretakers while in the clinic and all children must wear shoes. Patients must not hold a child while taking their medication. Patients must not bring animals into the clinic, and we ask you not to walk your dog on the premises. This is considered loitering. We ask all patients to leave pets in a well ventilated car while coming in for medication and not to bring any animal if you attend an individual session or group.

Staff expects all patients to be courteous even if you strongly disagree with a staff member's action or statement.

The clinic may withhold services and/or start a rapid medical withdrawal if a client does not follow program rules and/or program staff is convinced that a patient is hurting other patients and the program.

Reasons for clinic to withhold services or start administrative withdrawal (detoxification) include:
l  Violence or threats, explosive hostile, or abusive behavior towards staff members at any place, or toward
any person if it occurs in or near the clinic
l  Carrying a weapon (firearms, knives, etc.), alcohol or illicit drugs in clinic or its surrounding
l  Refusal to pay for services or not following through with fee arrangement agreements
l  Offer of bribes -- overt or covert -- or blackmailing of staff
l  Theft within the clinic and its surroundings
l  Loitering and socializing around the clinic, and other repeated behaviors which may be interpreted as dealing drugs,
trying to sell or buy takehome dosages, etc.
l  Continuous use of illicit drugs or alcohol as evidenced by appearing intoxicated at the clinic or its surroundings
l  Continuous refusal to participate in any form of counseling while clinic staff strongly feels that you do not benefit
from treatment (continued drug abuse, criminal behavior, frequent missing of medication, repeatedly not following
program rules and specific warnings)
l  Clients may be withdrawn or admission/readmission may be refused if clinic staff has strong indications that they
may be an informer or intends to harm a present client of this clinic 


7. INFORMATION FOR METHADONE PATIENTS (per JCAHO regulations)

revised 1/03

Natural Course of Addiction, Particularly Opiate Addiction

Abuse behaviors normally develop when people are exposed to addicting drugs and have no particular defenses, such as fear of drugs, insight, positive goals and values that exclude the use of drugs, etc. Abuse behaviors tend to spread or expand, comparable to a mental cancer, and psychological addiction develops when most thoughts, feelings and behaviors become involved in drug abuse behaviors, and if drug abuse behavior becomes regular and seemingly natural to the person. Addiction becomes a core disturbance of the emotional-behavioral system. Opiates are psychologically extremely addicting and physiological dependence makes it even harder to stop an addiction pattern. The natural course of addiction is waxing and waning with attempts to "kick", failed episodes of treatment and relapses. Generally, the addiction becomes gradually worse as the patient develops higher tolerance and more sophisticated drug seeking and drug use patterns. Occasionally, opiate addicts are able to benefit from relatively short courses of treatment, but a high rate of these clients become alcoholics. Later in life, and particularly after long-term treatment, the prognosis tends to improve. Moves, therapy, joining a religion and other significant factors that contain external as well as internal elements, may improve the chance of successful change. The prognosis is made worse by any other drug abuse, even cigarette smoking, and emotional problems such as anxiety and mood disorders.

Treatment Alternatives

Opioid agonist (methadone/Suboxone) treatment essentially cures the psychological addiction and allows the patient to work on psychological issues, particularly stopping all other abuse patterns, learning stress and pain management techniques, dealing with anxiety and depression, including PTSD and unresolved grief issues, and learning specific relapse prevention techniques. While in opioid agonist treatment, a client may have substance abuse behaviors, including social drinking and lapses of heroin use, without relapsing; in alternative treatments, a lapse almost always leads to full relapse. It is possible to relapse into a drug addiction (tranquilizers, alcohol, heroin) while on methadone, however, opiates and alcohol are much less enticing and psychologically addicting while in opioid agonist treatment. Relapses while in opioid agonist treatment often lead to non-compliance with treatment and dropping out of opioid agonist treatment. Without group learning and counseling, opioid agonist treatment has a relatively poorer prognosis, although many clients are quite stable as long as they are on the medication.

Non-pharmacological treatments work well, if they include long-term treatment with initially very structured environments, e.g. long-term residential treatment. Offered short-term treatments, e.g. one month inpatient, one month intensive outpatient, may work in highly motivated patients but have generally a poor prognosis. Rapid medical withdrawal ("detoxification") treats only the physiological dependence and has generally a very poor prognosis.

Withdrawn clients may do well on the antagonist Revea which blocks any opiate/opioid the client may try to abuse and decreases the "high" of alcohol. However, polydrug abuse continues to be a problem, including alcohol abuse – alcohol still feels like a tranquilizer. In addition, most clients using Revea cooperate with treatment while doing well but stop the treatment when they are most in danger of relapsing.

Summary of Confidentiality Policies and Regulations

Treatment at this clinic, medical and psychiatric records are strictly confidential. Staff often have to share and review information, and supervisors, even outside surveyors and Health Department representatives have access to all records, but they are themselves sworn to strictest confidentiality. Cleaning is done by a family that is ethical. They must not read records they may see and it would be highly illegal for them to disburse any name or information to outsiders. The computers are not connected to the internet. They are strictly used for in-house data storage.

Without a specific, written consent, we cannot acknowledge whether a person is or is not a client of this clinic. This applies even to spouses. We cannot talk to friends or well meaning relatives. FBI or CIA agents, police, probation and parole officers cannot get access to chart information without the client's specific written consent. The consent has to state what information may be shared, for what purpose and within what time frame.

There are situations when we may give information to outsiders without your consent:
- When there is a suspicion of child or elderly abuse staff is obliged by law to report basic information to the Department of Human Services.
- When a judge finds it in the public interest to subpoena a chart – public interest mostly refers to the interest of a young child, i.e. when there is a question whether a client is able to take care of his/her young child or when there is a custody battle and the court must decide what parent is better able to take care of a child/children. The regulations are somewhat unclear when records may be requested by a court, however this is very rare.
- When a client is treated in an emergency room, clinic or hospital, sharing basic information between medical staff is considered medically urgent. (We informally consult with physicians who call us, often without giving specifics about a patient.)
- When staff considers a client to be imminently dangerous to self or others, e.g. if the client is considered acutely suicidal, necessary information may be given to police or closest relatives.
- If the client breaks a law involving clinic and/or clinic staff, necessary information may be given to police.
- When the client is deceased, the next of kin and the coroner have the right to receive copies of the chart.

Infectious Diseases Associated with Addiction and Ways to Avoid Infection

Some diseases can be spread by breathing in droplets coughed up by patients with diseases such as tuberculosis or flu. The danger of such infections is particularly high when people in ill health stay/live very close together, e.g. in refugee camps, jails and prisons, or in closed-in places where air is recirculated, such as in air planes. Danger of infection is decreased by keeping some distance and by wearing a mask. Generally good physical and mental health and good nutrition including use of Vitamin C may be somewhat protective.

Many diseases are spread through water, food and smear infections (hand to hand, door knobs to hand and eventually into food or drinks). Occasionally, infections are directly transferred from skin infections and infectious rashes. General hygiene, particularly hand washing, avoids most of these infections.

Diseases, such as sexually transmitted diseases like gonorrhea, trichomonas and herpes, can be transferred through body fluids and contact of mucous membranes. Danger of infection can be decreased by using condoms and certain spermicides. If there is likelihood of disease, avoiding physical intimacy is advised, unless both partners have been checked and/or treated.

Virtually all infectious diseases can be spread through blood (e.g., sharing needles).
HIV (the AIDS virus) is spread mostly through needle sharing, and sex. The HIV virus accumulates in semen (ejaculated prostate secretion) and is easily transferred from man to woman and man to man, though much less easily from woman to man. Anal sex is particularly dangerous. A person is most powerfully infectious during the first few months of HIV exposure (before showing a positive test for HIV) and in the terminal stage of the disease. When the person is most infectious, he/she is often quite ill, but not always.
Hepatitis B is readily spread through sexual contact and traces of blood.
Hepatitis C is mostly spread through traces of blood, e.g. needle sharing, sharing of razors or toothbrushes, very rarely through kissing, but less through intercourse. The hepatitis C virus is particularly dangerous because it survives months of dryness, so it can remain on old needles or razors for a very long time. Hepatitis C and particularly hepatitis B are more infectious than AIDS. In a needle stick with an almost clean needle, transmission of hepatitis is much more likely than transmission of HIV. The danger of infection can be somewhat reduced by cleansing needles. This would entail washing and heating them or washing them and rinsing them in bleach multiple times (see below), and by using condoms combined with spermicides. Infections can be avoided by never sharing needles, razors, tooth brushes, etc., always using sterile equipment, and by avoiding sex with persons who were recently exposed to possible infection or are known to be infected.

To clean needles: (1) Rinse syringe with needle attached three times by drawing in small amount of air, filling syringe through needle with water, shaking it in different directions for 30 seconds needle pointing down, then pushing water out. (2) Pour small amount of bleach into cup and clean syringe with needle by repeating above procedure using bleach instead of water. (3) Repeat step (1) using clean water.

8. GENERAL RECOMMENDATIONS FOR ALL CLIENTS

Frequent aerobic exercising:  running, bicycling, swimming, etc. is most helpful for all clients, unless there is a specific medical problem that makes such exercising dangerous. Exercise to the point where you could not talk continuously but not so intensely that you could not have a conversation. Look at aerobic exercise as the oil that lubricates body and mind: without exercise, people become unhealthy, anxious and depressed.

Diet:  Make efforts to follow a healthy diet – mainly avoid sweets, foods high in fat content (particularly saturated and hydrogenated fats), and salty foods. Avoid also sweet drinks. Soy products are particularly healthy. Cold water fish, fish oil, flax seed and/or flax seed oil are rich in essential fatty acids that are needed by the nervous system and may be mood stabilizing.

Supplements:  Use daily multivitamin preparations with minerals. For women, folic acid, calcium and vitamin D are particularly important (Tums are a good source of calcium). Selenium and zinc supplements may be valuable. Avoid extra iron, except if there is known blood loss and iron deficiency anemia. Too much iron is toxic, particularly in patients with hepatitis C or other liver disease.

Over-the-counter medications:  Avoid frequent use of over-the-counter medications. Tylenol, Aspirin, ibuprofen, etc. are possibly dangerous and lead to tolerance and withdrawal headaches when discontinued. If you use much of these medications, decrease them gradually over a few days. However, very low daily doses of aspirin may be helpful in many ways.

Avoid frequent or regular use of laxatives, other than fiber. Instead exercise often, drink enough fluids at soothing temperature (not ice cold, not iced tea), avoid constipating foods, and eat a lot of fruits and vegetables.

Be careful with herbal products. Some are toxic when taken in high dosage, and many interact with medications you may be taking. Discuss herbal products with a knowledgeable pharmacist, particularly if you are on medications for a chronic disease. For instance, St. John's Wort is a good antidepressant, but it is not safe in pregnancy, may interact with other antidepressants and decongestants, increases danger of sunburns, and may interfere with some other medications.

 

9. FREQUENTLY ASKED QUESTIONS

Is methadone more or less addicting than heroin or Dilaudid?
Heroin, methadone and other opiates and opioids (synthetic narcotics) lead to the same physiological opioid dependence; however, there is essentially no psychological addiction to methadone while heroin is extremely psychologically addicting.
With regard to withdrawal symptoms, the main difference is how fast the drug's blood level drops if discontinued, and whether withdrawal is longer and very intense or shorter and less intense. Withdrawal is extremely acute and lasts only about 30 hours, when a potent antagonist (naltrexone [Revea]) is taken, no matter which opiate or opioid was taken. Dilaudid leads to the most rapid and most intense withdrawal, while heroin withdrawal lasts about six days. Stopping methadone is like gradually decreasing heroin over ten to fourteen days, so it is like decreasing heroin over a few weeks. However, most methadone clients report more severe withdrawal after having been on opioids for years as compared individuals with a relatively short heroin addiction.

Does methadone "get into your bones" or cause dental problems? Is it bad for your health?
No, methadone is not toxic and does not damage any body tissue. However, when starting methadone, clients often become aware of the consequences of bad health habits, and withdrawal symptoms include hurting bones and joints.

Opiate addiction often includes craving for sweets and poor dental hygiene. Some patients continue to overeat carbohydrates when on methadone and become less physically active. This may lead to weight gain.

Most methadone clients are hepatitis C positive and/or have histories of ingesting liver toxic substances (such as alcohol). Long experience shows that methadone appears to have no ill effect in these clients. Liver disease is no contraindication for methadone treatment.

How long should I stay on methadone?
Generally, at least twelve to eighteen months. Most clients need longer treatment. Very few people can withdraw within a few weeks or months without relapsing immediately or within a few months

The following are likely to help you withdraw relatively early:
Do not use any drugs, alcohol or addicting medications while on methadone.
Attend many groups at this clinic and follow homework and recommendations.
Learn and practice stress and pain management technique.
You are relatively healthy and have no major mental health issues, stress, etc.
Do not smoke.
Abstain from psychological addiction behaviors, such as food addiction, gambling,
consumerism, or inappropriate and dangerous sex.
Have strong positive motivation, possibly due to religion and/or spirituality, focus on family, and other goals that
exclude drug use and that you highly value.
Do not increase your methadone dosage, once you are adjusted.
You are able to decrease your dosage without fear and increased anxiety.

What does methadone do and not do?
It essentially "cures" your addiction. You are no longer continuously thinking of getting "high" or avoiding withdrawal, or getting the drug. Methadone clients generally still have abuse thinking but are no longer addicted. Addiction is a psychological state in which the drug and/or addictive behavior is your first priority, ahead of all other motivating factors in life. Physical dependence is often independent of abuse/addiction, many people are physiologically dependent on medications for medical or psychiatric diseases and many addictions are purely psychological.

Methadone reduces craving but does not completely stop it. Craving is often due to psychological and other factors, including fear, stress, being reminded of drug abuse or feeling physically ill. Some people are not willing to stop illicit drug use. Even while on methadone, relapse into daily heroin abuse is possible.

There is decreased craving for alcohol while on methadone. Clients tend to drink relatively moderately, if they do at all. However, when withdrawing, some will considerably increase their drinking. Approximately a third of former methadone clients become alcoholics, and more social drinkers than non-drinkers relapse after withdrawal from methadone or other opioids. We urge you not to drink any alcoholic beverages, while on methadone and for the rest of your life.

One to four hours after taking methadone, you may feel as if you used heroin a few hours ago, but you should never feel "high.” If you do, your dosage is too high. You should be essentially tolerant to this medication, meaning you should hardly feel it. With methadone, you should always feel "normal.” Thus you should feel normal stress and anxiety as well as normal pleasures.

Methadone helps clients in their treatment of psychological problems but it is not a permanent cure. Ex-opiate addicts are permanently at risk of relapse, particularly if there is severe stress and/or physical pain. This is why it is critical to address the psychological aspects of addiction by attending groups and individual appointments while in treatment.

How is Suboxone different from methadone?
1) Suboxone is less potent than methadone and it has a maximum dosage approximately equivalent to 30-40mg daily. Above that there is no benefit in increasing the dosage; 2) Suboxone blocks all other opiates at moderate to high dosage; 3) Suboxone is long acting but usually taken daily; 4) Suboxone is much more rapidly absorbed and abusable but safer in overdoses (except if combined with alcohol or other drugs); 5) Suboxone is much less regulated than methadone; 6) Suboxone is much more expensive.

What are frequent side effects of methadone? What can be done about them?
Sedation or feeling "high", "wired", if the dosage is too high - decrease dosage significantly
Small pupils: "pin-point" pupils may be a sign that your dosage is too high - decrease dosage significantly
Constipation: eat a lot of food with fiber such as vegetables, fruit (except bananas), bran, etc.; exercise; drink enough fluids (except iced tea), preferably warm or room temperature; you may also use bulk laxatives, stool softeners, prune juice and/or herbal laxatives; generally avoid frequent use of potent laxatives and enemas; avoid constipating foods, such as chocolate, cheese, black (regular) tea
Sexual side effects: women may have no periods, but still may ovulate and become pregnant; men may become more or less impotent; both genders may have decreased sex drive and delayed orgasm - women should have regular check-ups and use birth control; not having menstrual periods is not a problem; to improve sexual functions, be patient, spend time intimately without sex (may include stroking and massaging places other than genitals and breasts); other measures: dosage decreases; avoidance of other medications that decrease sexual functions; sildenafil (Viagra) may be helpful
Water retention: (rare; in women more often than in men) - eat much potassium containing foods (vegetables, fruit); drink adequate fluids; diuretics may be indicated

Increased sweating

Dry mouth (rarely) and difficulties starting to urinate (urinary retention) - avoid other medications that lead to urinary retention; rarely specific medications needed

What should I do if I miss methadone?
1) Do not panic. Withdrawal symptoms are minimal in the first few days. You may take Benadryl (over-the-counter and cheap) at night, and in case of aching, use Tylenol, ibuprofen or similar medications. Do not use heroin or other addicting drugs.
2) Call 444-5092 and leave a message explaining why you could not come.
3) Fill in an "Explanation for Missing Scheduled Day of Methadone Dosing" form, when you return.

What happens if I drink alcoholic beverages?
Alcohol abuse is more dangerous, when you take opiates/opioids, with regard to intoxication and overdose.

Alcohol, even in small quantities, increases the metabolism of methadone, that is, methadone blood levels drop more rapidly and you may get withdrawal symptoms.

Is it all right to use abusable drugs/medications I am not addicted to?
No. It is your decision when you want to stop other drugs, such as marijuana, cigarettes, alcohol, however, these addictions are severe and need to be addressed. They worsen the prognosis of your opiate addiction.

Should I tell my doctor and dentist that I am on methadone?
Yes. Let him/her know that you do not want any abusable/addicting medications and that the psychiatrist at this clinic will handle pain and anxiety medication, if needed. Addiction and Psychotherapy Services staff are always willing to consult with your doctor or dentist.

It is particularly important that your doctor knows about methadone treatment if there is a possibility that you need surgery or other procedures with general anesthesia or an induced twilight state.

If you are pregnant, see an obstetrician as early as possible and let him/her know of all medications you receive from us. We are glad to communicate with your obstetrician to clarify concerns regarding your treatment.

Let us know and sign a “Consent to Release Information” form so that we can communicate with your doctor, if indicated.

Do I need to tell staff of this clinic about my seeing another doctor and getting prescriptions from him/her?
Yes. Some medications interact with methadone and may lead to problems. Your general health is of concern in our treatment. We try to help our clients with appropriate treatment, preventive medicine, healthy life style and other issues.

If you see another psychiatrist or psychotherapist, please discuss this treatment with your case manager. If you have an appointment with the clinic physician/psychiatrist, let him know.

What should I do for pain while I am on methadone?
Try to determine whether you suffer from a problem that needs medical attention, e.g. an abscessed tooth, a broken ankle, appendicitis, kidney stones, etc. Whether or not you see a family doctor or go to an emergency room, let your case manager know about your pain. Although methadone is a most potent pain medication, if you are tolerant you will feel little or no pain relief from it unless your dosage is temporarily increased. It is safe and helpful to take over-the-counter pain medications in addition to methadone (Tylenol, Aspirin, ibuprofen or another).

If a physician gives you narcotic pain or cough medications (e.g. Vicodin, codeine containing cough syrup, Darvon, or Ultram) see whether you can handle the discomfort/pain with over-the-counter medications first. If not, please bring the prescription in and trade it for a dosage increase. These medications help little if added to methadone.

Attend an acupuncture group, a pain management group, and/or bring the problem up in the "Ask the Doctor" group. (Acupuncture is usually available outside acupuncture group times at a fee of $ 5.00.)

If the pain is difficult to tolerate and/or leads to craving, ask for a temporary dosage increase.

Why should I not use Vicodin, Xanax and other controlled prescription medications that I received from my doctor?
Methadone largely blocks the effects of other opiates, such as opiate pain and cough medications including Tussinex, Vicodin, codeine, Ultram and Darvon.

Most controlled medications lead to a urine specimen showing positive for an illicit substance.

Valium, Xanax, and other benzodiazepine drugs are abusable, lead to tolerance and may lead to addiction, particularly in persons who previously had an addiction to other drugs. You may have been able to use these medications responsibly before becoming addicted to opiates, however, the danger of addiction to these drugs is considerably increased while you are on methadone – and even more so when you withdraw from treatment (detox). Anxiety is best treated with counseling, relaxation/stress management techniques, and antidepressant medications rather than tranquilizers.

Especially when on low dosage methadone or after withdrawal from treatment, controlled medications, such as Ultram or Vicodin, often lead to drug craving and relapse. And drugs like Xanax may lead to a new addiction.

What should I do if I am ill?
If you seem to have a benign illness, such as a viral infection, food poisoning or seasonal allergies for example, use over-the-counter medications. Do not use opiates and, generally, do not ask for a dosage increase unless you have a cough or pain which you have difficulties handling.

You may talk with your case manager, attend an acupuncture or pain management group. (Acupuncture is usually available outside acupuncture group times at a fee of $5.00.)