If you read my blog, you know Tennessee is a frequent target of my ire. I’ve been aghast and distressed at Tennessee’s refusal to allow an opioid treatment program to open in the Eastern part of that state. Hopefully, that’s about to change.
Now a new opioid treatment program has applied for a certificate of need with Tennessee’s Department of Mental Health and Substance Abuse Services, asking for permission to locate a methadone clinic in Eastern Tennessee. Sources say this is the eleventh attempt to locate an opioid treatment program that prescribes methadone in that part of Tennessee. In 2002, approval was given but then withdrawn due to a technicality.
Even if the certificate of need is approved, this company faces stiff opposition from the modern-day equivalent of villagers with pitchforks, demanding that no treatment center be located near them. This is the ugly face of modern day NIMBYism, and it violates the American with Disabilities Act, a topic of a past blog. (See November 14, 2012) It’s illegal, and past federal court rulings have sent a clear message to towns that violated the ADA in this way, with high six-figure fines.
I’m surprised anyone wants to put a new clinic in Tennessee, given its recently passed anti-evidence-based regulations on methadone clinics, but I’m pleased. Eastern Tennessee probably has more untreated opioids addicts per acre than anywhere else in the nation. Tennessee has the 13th highest opioid overdose deaths per capita, compared to all other states, and is ranked number two in the kilogram of opioids prescribed per capita. 
Yet it has only a small number of opioid treatment programs. The nearest methadone clinic to Eastern Tennessee is located in Knoxville, and in bordering states. These states treat the opioid addicts Tennessee is neglecting. The certificate of need submitted by the petitioning opioid treatment program says that around one thousand opioid addicts are now traveling one or two hundred miles round trip each day for treatment. You know there are thousands more getting no treatment at all.
The state will make a decision about the certificate of need request this summer. Of course, any educated interpretation of data would conclude that the certificate of need should be approved forthwith. As I said, you can’t throw a rock in Eastern Tennessee without hitting an opioid addict. But so many people don’t know anything about the benefits of methadone.
Lack of knowledge about methadone does not prevent people in positions of authority from taking a strong stance against it. For example, this is a quote in the Johnson City Press from Roger Nave, committee chairman of the public safety committee of the county where Johnson City is located: “We have top-class medical facilities in this area to deal with any problem that our citizens have. The addicts do need help and support, but methadone is not the answer to their problems.”
Does Mr. Nave actually know any facts about methadone?? Does Mr. Nave know that the treatment of opioid addiction with methadone is one of the most strongly evidence-based medical treatments in all of medicine? Does he know that we have over forty years’ of studies that show the treatment of opioid addiction with methadone reduces overdose death rates and suicide rates? Does he know it improves employment rates and dramatically reduces crime rates? Does he know addicts treated with methadone have better physical and mental health? Does he know that for each dollar spent on methadone treatment, taxpayers save four dollars, mostly in reduced incarceration costs? Does he know that methadone treatment of opioid addiction significantly reduces the incidence of HIV in intravenous opioid addicts? [2,3,4]
Eastern Tennessee now has Suboxone providers, and these doctors have likely saved hundreds of lives. Buprenorphine is a great medication, and I prefer prescribing it rather than methadone because of its better safety record. It works on the same principle as methadone: both are long-acting opioids that can be dosed once daily to keep opioid addicts from having withdrawal or craving, thus freeing them to focus on changing their lives.
But buprenorphine is not strong enough for all opioid addicts. It doesn’t work for all opioid addicts. In fact, no treatment works for all opioid addicts, even medication-assisted treatment with buprenorphine and methadone. Some are too sick for these medications, and some aren’t sick enough.
Suboxone programs are too expensive for many addicts. Yesterday I called three programs in Tennessee to get an idea of their prices. A month’s worth of treatment is around $400, including doctors’ visits, group and individual counseling, and drug tests. The medication is not included in this cost, and can cost an additional $240 to $900 per month, depending on the dose of medication. Opioid addicts without health insurance can’t afford that kind of treatment. Methadone programs usually cost $9-$11 per day, and addicts can pay as they go.
At least one big Suboxone program in Johnson City doesn’t do maintenance treatment, but only a few months of detox, despite more studies showing greater benefit with longer treatment. Some addicts are forced to come off Suboxone before they are ready, a recipe for relapse.
Suboxone is a valuable option for opioid addicts, but let’s make all forms of evidence-based treatment available for opioid addicts. Why not let addiction specialist doctors decide which treatment is appropriate, rather than government officials without any medical training?
With so many untreated opioid addicts in Eastern Tennessee, all forms of evidence-based treatments need to be available. At present, health officials in Tennessee push patients into medication –free treatments. These can work, if patients are given long enough treatment and if they can afford it. In my experience, inpatient programs in Eastern Tennessee seem to keep patients for two or three weeks, instead of two or three months. This is understandable, since Medicaid isn’t known for generous reimbursement, and private insurance rarely pays for longer treatments. Patients with no insurance at all are often asked to bring money up front to pay for treatment. Asking an addict to bring a few thousand dollars with them to start inpatient treatment doesn’t work, for obvious reasons. Even treated patients are sent back home to the same living situation, and relapse quickly. Using inpatient detox alone for five to seven days has always given relapse rates of 92%, with most relapsing within the first week.
Tennessee state officials have a chance to save lives, if only they can put aside their personal biases and look at the science supporting medication-assisted treatments. It’s the right thing to do. It’s a bargain, too. Patients are mostly self-pay, so it doesn’t cost taxpayers anything. Even from a purely economic view, methadone treatment would save taxpayers money.
If you support medical treatment of opioid addiction with evidence-based therapies, please write to the state and let them know. If you are an addict who has been helped by methadone, send a letter to the below address. If you are a family member who has seen the benefits of methadone treatment in your loved one, tell the people in government. This is the time to act. Don’t let this opportunity to slip by. Send your letter to:
Tennessee Health Services and Development Agency
Melanie M. Hill, Executive Director
Frost Building, 3rd Floor
161 Rosa L. Parks Boulevard
Nashville, TN 37243
3.California Department of Drug and Alcohol Programs, 2004, California drug and alcohol treatment assessment (CALDATA) California Department of Alcohol and Drug Programs. California Drug and Alcohol Treatment Assessment (CALDATA), 1991-1993 [Computer File]. ICPSR02295-v2. Ann Arbor, MI: Inter-university Consortium for Political and Social Research [distributor], 2008-10-07. doi:10.3886/ICPSR02295