DOI: 10.1097/JCP.0b013e3181c8b439
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PMID: 20075667
Issn Print: 0271-0749
Publication Date: 2010/02/01
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Excerpt
We were very interested to read the article of Elkader et al1 showing that depressed methadone-maintained patients report significantly more dysphoric opioid effects and subjective opioid withdrawal symptoms over the dosage interval compared with nondepressed patients and that nonholder methadone patients have significantly higher exposure to unbound (S)-methadone over the entire dosing interval compared with holders. This last finding suggests, in the authors' own words, that (S)-methadone may relate to patients' dissatisfaction with methadone treatment.
Throughout the article, Elkader et al1 used the terms satisfaction with methadone treatment and holder status (holders vs nonholders) interchangeably, as synonyms. In fact, patient satisfaction with methadone treatment is operationalized by means of the methadone holding status. This operationalization is not uncommon. For example, Hiltunen et al2 also characterized satisfied versus dissatisfied patients on methadone maintenance treatment (MMT) according to the absence or presence of complaints of insufficient methadone dose. However, we would like to discuss the key differences between the different constructs related to methadone treatment satisfaction because they may compromise the suitability of the aforementioned operationalization.
From both a research and clinical perspective and despite their interrelated nature and overlapping specificities, it is worth distinguishing between holding dose, dose adequacy, satisfaction with methadone as a medication, and satisfaction with treatment. These 4 constructs highlight the necessity for an individualized approach to both the methadone dose adjustment and the treatment process as a whole. The first 2 constructs include both subjective and objective data, whereas the latter 2 are arguably subjective phenomena.
A holding dose of methadone can be defined as the dose of methadone that prevents subjective and objective opioid withdrawal symptoms over the entire 24-hour interdosing interval.3 This construct therefore seems to be limited to signs and symptoms of undermedication.
González-Saiz et al4,5 defined an adequate dose as the amount of methadone that allows the patient (a) not to use heroin or to use it only occasionally; (b) not to experience continuous opioid withdrawal symptoms or to experience only very mild ones; (c) not to experience frequent episodes of heroin craving or to experience only uncommon, mild episodes; (d) in the case of heroin use, to hardly experience any subjective effects (opioid cross-tolerance) or to experience only very mild ones, if any; and (e) not to show signs and symptoms of overmedication or only to a small extent. Therefore, the construct of dose adequacy covers the narrower definition of holding dose.
Satisfaction with methadone as a medication can be defined as the patient's evaluation of both the process and outcomes of taking methadone.6 Some of the core domains of satisfaction with medication are effectiveness, adverse effects, convenience of use, and impact on daily life/functioning.7,8 Therefore, satisfaction with methadone as a medication encompasses both the holding dose and the dose adequacy constructs.
Satisfaction with MMT reflects patients' evaluation of the care actually received, compared with their care expectations.9 Satisfaction with MMT is thus a broader construct, involving evaluation of more than just satisfaction with methadone as a medication. The assessment of patient satisfaction with MMT as a whole entails including areas such as nonpharmacological interventions, accessibility, professional's skills and behavior, and other aspects of biopsychosocial care, service, and delivery.
These 4 overlapping and closely linked constructs are all necessary conditions for ensuring optimal MMT outcomes, but they are insufficient in themselves. Any of the 4 constructs may affect the other ones.6 The most common of these interrelationships is the projection of patient satisfaction with medication onto the entire treatment experience.
