Volume 22, No. 12, March 2025

Welcome to the March edition of Tips and Topics.

In SAVVY, in reviewing the manuscript for "Navigating the Methadone Maze: A Guide for Patients and Professionals," I had some concerns about the quality of counseling in Methadone Maintenance Treatment (MMT).

In SKILLS, even if taking a Harm Reduction approach for people suffering from Opioid Use Disorder, don’t give up on helping the client move in the right direction. Use counseling for their growth and development.

In SOUL, my granddaughter’s teenage birthday reminded me of Gail Sheehy’s 1977 book "Passages: Predictable Crises of Adult Life." How will my grandgirl handle each of life’s passages? Will she realize the opportunity for creative change and grow to her full potential? How many examples of age-related change will I be granted the opportunity to witness and enjoy in the sunset of my life?

A longtime colleague, William Santoro, M.D., recently asked me to review a manuscript of a book he and his co-author have just written. Bill said: “I recently shifted the trajectory of my career and suddenly found myself with extra time on my hands. Determined to use it productively, I began writing a book that had been on my mind for years — an idea originally conceived with my friend and colleague, Dr. Peju Simoyan.”

Doctors Santoro and Simoyan plan on publishing "Navigating the Methadone Maze: A Guide for Patients and Professionals" in June, 2025. Bill wrote: “Recovery from opioid use disorder is one of the most profound journeys a person can undertake. The aim of this book is to provide you with practical advice, clear information, and the encouragement needed to take those steps towards a healthier and more fulfilling life.”

I am no expert in Methadone Maintenance Treatment (MMT), which is one of the reasons Bill wanted me to review the manuscript. He wanted to see if the tools, strategies and resources seem like they would be helpful for a person’s recovery journey and a knowledgeable resource for professionals not familiar with MMT. So in that context, here are some thoughts and observations that arose for me, specifically about counseling and MMT.

Tip 1

Engaging with Counseling and Therapy are essential components of MMT, but many programs seem to do counseling only to meet mandatory regulations.

The focus and frequency of counseling should be based on assessment of stage of change and actual progress or not in treatment. Over the years in case reviews, I have heard many counselors report that their clients are still using other substances and yet the MMT continues with only cursory assessment and motivational work.

Basic assessment of continued use in clients on MMT should include:

• Is the client not stabilized on sufficient methadone to address cravings and/or withdrawal symptoms?

• Is the client using other substances to medicate physical and/or mental health problems?

• Is there a stage of change issue such that the client is not interested in abstinence and recovery?

• Is the client well motivated for recovery but lacks the skills to prevent relapse or continued use?

• Are there recovery support services that are needed to support abstinence from other substances?

Tip 2

The most important member of the MMT team is the client. Their daily decisions and actions play a significant role in determining treatment outcomes.

Excerpts from the book:

“Methadone maintenance is not just a treatment; in a good program, it is a bridge that allows individuals to transition from the chaos of addiction to the stability of recovery, offering the opportunity to rebuild lives and relationships.

“For patients starting methadone maintenance, remember your healthcare providers and counselors are part of your team, committed to helping you succeed. However, when it comes to your personal recovery, you are the most important member of that team, as your daily decisions and actions will play a significant role in determining your outcomes. Your team will help and support you, but they cannot make decisions for you. I hope that the tools and resources in this book will be helpful to you in your recovery journey.”

William Santoro, MD, FASAM, DABAM
Olapeju Simoyan, MD, MPH

SKILLS

Tip 1

Even if taking a Harm Reduction approach, don’t give up on helping the client move in the right direction.

The rationale for continuing MMT while the client still uses other substances seems to be, understandably, that it is better to continue the MMT indefinitely than to have a person overdose and die. While I agree with that, it seems to me that the team should then decide:

• Which people are they going to designate as harm reduction patients where the focus will be more on medication adherence than counseling?

• Which people are they going to really try to attract into recovery; continue the methadone, but be free of other drugs?

• This would require careful assessment and motivational enhancement work involving family or significant others as well as accountable, shared decision-making, individualized treatment planning and outcomes monitoring in real time.

This is how Bill responded when I raised my concerns about the quality of counseling in many MMT programs: “I am thinking I will... get across the point that counseling should NOT be done just to check the regulation box. It should be used for growth and development. And even if it is used for harm reduction, a constant guidance to try to have the patient move in the right direction is still beneficial.”

Tip 2

Help MMT clients to start with just one “day-at-a-time” goal.

Bill:
"I was a family physician for more than 30 years, but my journey into Addiction Medicine began unexpectedly early in my career when I covered for a colleague on vacation. I met a patient who completed the following sentence: 'JUST FOR TODAY… I want to not trade sex for drugs.'; This was not a long-term goal — it was a desperate hope for just one day.

"That single sentence convinced me that I needed to help more people like her. I included addiction medicine in my everyday practice of family medicine, and it gradually grew until I did nothing but addiction medicine.”

Doing recovery “one day at a time” applies not only to MMT, but to all addiction and mental health treatment. It actually is relevant for all behavior change, which can seem like an unsurmountable task and journey.

• How do you eat an elephant? One bite at a time!

SOUL

I am writing this month’s edition from Hawaii. I am here to celebrate my granddaughter’s 13th birthday. It reminded me of Gail Sheehy’s book “Passages: Predictable Crises of Adult Life” that was published in 1977, the year I graduated from specialty psychiatric training to make the passage into full “professional” life.

Gail’s bestseller showed “how to use each life crisis as an opportunity for creative change — to grow to your full potential.” I have experienced the growth that has come from the passage of:

• Student to professional

• Childless, married couple to parents of three

• Married couple to widower

• Full time professional to retired person

As I observe my granddaughter’s passage from pre-teen to teenager, it is fun to identify “patterns of age-related change” and compare “the developmental rhythms of men and women,” which Sheehy’s book did.

I think back to:

• The joy of holding our first grandchild 13 years ago

• Supporting the worried parents as they struggled to soothe their crying baby who just needed burping and relief from stomach gas

• Rejoicing in her first steps, her first bicycle ride (no training wheels), her first school day, her first piano performance and many other “firsts”

How will she handle each of life’s passages? Will she realize the opportunity for creative change and grow to her full potential? How many examples of age-related change will I be granted the opportunity to witness and enjoy in the sunset of my life?

Happy Birthday my beloved teenager.

UNTIL NEXT TIME

Thank you for joining us this month. See you in April.

David