Safer Solutions: What happens when a person misses a methadone dose?

Most of us miss a dose of medication from time to time: We realize we’ve missed a day (or two!) of the birth control pill, or we can’t remember if we’ve taken our blood pressure medicine on a busy day.

Now imagine having to travel every day to get that medication. That’s the reality for many people taking methadone as treatment for opioid addiction. The causes and consequences of a missed methadone dose are more complex than for most medications, mainly due to the unique and extremely strict regulations around access to this lifesaving medicine.

Considered a “gold standard” treatment for opioid addiction, methadone offers better outcomes than many other recovery pathways. However, it’s also the most highly regulated medicine in the United States. Federal restrictions allow only one channel for access: specialty clinics known as opioid treatment programs (OTPs). Many patients are required to visit the OTP every day to take their methadone dose, while some qualify for a limited supply of “take-home” doses that must be refreshed via return visits to the clinic. OTPs can be scarce outside of urban areas; in fact, 77.5 million Americans live in a county without an OTP, and the average nationwide commute to an OTP is 45 minutes. Additionally, some OTPs are open only a few hours each day.

People in treatment for opioid addiction work hard at it, but getting to the OTP daily can be difficult. Distance and time barriers are exacerbated by work and family obligations—both of which are beneficial to recovery and expected by society—as well as mundane hurdles like illness, child care gaps, public transit delays, and car trouble. It’s no wonder that roughly a quarter of methadone patients sometimes miss doses.

Missing a single dose of methadone affects each person differently. Some can make it to the next day without many negative effects, while others go into painful, unsustainable withdrawal, which can spark a return to the deadly illicit drug market simply to relieve their symptoms enough to complete daily activities.

But what can happen after doses are missed further illustrates the weaknesses in our current system of methadone access. Some states allow OTPs to kick patients out of treatment for missing multiple doses or counseling appointments. As one OTP employee explained in a recent study, this practice is counterintuitive because it can push patients into withdrawal, out of treatment, and back to the illicit market.

Even if OTPs don’t discharge for missed doses, many will reduce a patient’s dosage after two or more consecutive absences. While federal guidelines don’t dictate specifics, they do state that a patient who misses more than four doses should be reevaluated and have their dose temporarily reduced before gradually building it back up. This is often done in the name of patient safety, based on the assumption that a few days off methadone could render the patient’s tolerance lower.

But lowering a patient’s dose without considering their individual circumstances can increase the likelihood they will return to using illicit drugs in order to prevent withdrawals and could push them to drop out of care altogether. In one study, a patient reported that his dose was reduced after he missed two days in a row—one because of work, the other because he was just minutes late. He noted that the reduced dose “doesn’t carry you as long.”

Addiction medicine physician Ruth Potee takes a more realistic and patient-focused approach to missed doses. She says the federal guidelines assume that if a patient misses five doses, then they haven’t used any opiates in five days. “[W]e all know that’s not true,” she says. “[P]eople are still using opiates, they’re just not using methadone.” Potee doesn’t do anything differently for up to four days of missed doses; once a patient misses a fifth dose, she “cut(s) by 20 percent … and then we try to return them to their stable dose as soon as possible.”

For an individual to have consistent access to methadone under the current system, they must win a geographic lottery; have strong financial resources and social support networks; and get lucky with bus schedules, work schedules, family commitments, weather, and numerous other unpredictable factors. However, success in recovery should not be left to chance. Improving state laws and OTP guidelines and practices could offer incremental progress in both access and how missed doses are addressed. But a true paradigm shift in access and recovery for more people would require a diverse, competitive market for methadone—one that includes both OTPs and mainstream healthcare providers as access points for this medication.

Such a landscape could help people stay the course by eliminating major burdens and barriers that affect their ability to start and continue treatment. If it’s life, recovery, health, and stability we want, then better access—not barriers and punishments—will help get us there.