Archive for the ‘Local Governments Behaving Badly’ Category

Johnson City, Tennessee: Department of Justice Decision Due Soon

doj

Last week’s issue of Alcoholism and Drug Abuse Weekly carried an article about the battle to start a much-needed opioid treatment program in Johnson City, Tennessee. As most regular readers of this blog know, many efforts to start a clinic in that area have been shot down by both NIMBYism and poorly informed government officials.

After the state denied a certificate of need, necessary to open an opioid treatment program, the company seeking to start the OTP and other advocates complained to the Department of Justice. The complaint says both the state’s certificate of need process and local ordinances violate the Americans with Disabilities Act because they make it impossible for opioid addicts to be able to access an evidence-based form of treatment, that of methadone maintenance.

Zac Talbott, of NAMA’s Tennessee chapter, was quoted in the ADAW article. He’s also a frequent commenter to this blog, and in the ADAW article, he made the point that Tennessee’s certificate of need process discriminates against the opioid addict, and is literally killing people.

I was also quoted:

“And Jana Burson, M.D., a North Carolina internist who treats opioid addiction with buprenorphine and also works in an OTP, said medication-assisted treatment of
opioid addiction with methadone and “is one of the most evidence-based treatments in all of medicine, yet government officials in Tennessee have repeatedly interfered
with the delivery of this essential treatment to its citizens.”

Noting that Tennessee has a high rate of overdose deaths, Burson said “you’d think they would welcome help to treat opioid-addicted citizens instead of thwarting efforts to establish and opioid treatment program.”

Johnson City and other towns of Eastern Tennessee re-wrote their zoning laws in an effort to prevent methadone clinics from being established, said Burson. Even
though Johnson City’s attorney said there was no intentional discrimination against drug addicts, “history speaks for itself,” said Burson. “Multiple facilities have tried
and failed to get permission for a methadone clinic in that town over the last ten years.” Future generations will likely judge state and local officials harshly for
preventing the treatment of opioid addiction with methadone, since this treatment has been proven to save lives, she said.”

So we wait for the final word of the DOJ decision, which may be made public soon…

A Really Good Book – For Free

aaaaaabook

If you haven’t read CASA’s (Center on Addiction and Substance Abuse, at Columbia University) masterpiece publication from June, 2012, titled “Addiction Medicine: Closing the Gap between Science and Practice,” you should do so. This publication can be downloaded for free, and has essential information about addiction and its treatment. http://www.casacolumbia.org/addiction-research/reports/addiction-medicine

Casa also has other free and informative publications about other issues, like how to reduce the risk of addiction in teens (“The Importance of Family Dinners” series), the cost and impact of untreated addiction on society (“Shoveling Up”), substance abuse and the U.S. prison population (“Behind Bars” series), and the availability of drugs on the internet ( “You’ve got Drugs” series). All of these contain useful and thought-provoking data.

“Addiction Medicine: Closing the Gap between Science and Practice” outlines all aspects of what is wrong with addiction treatment in the U.S., along with recommendations about how we can fix this broken system. When it was published in June of 2012, I thought it would be would be widely read and discussed. However, I’ve only heard it mentioned once, and that was at an ASAM meeting. I wish popular press, so eager to write sensationalistic pieces about addiction, would write more fact-based information.

Every politician should read it. Every parent should read it. Physicians and treatment center personnel should read it. Anyone who is concerned about the extent of addiction and its poor treatment in the U.S. should read it.

CASA describes their key findings of the drawbacks of the U.S. system – or non-system – of addiction treatment. This nation is doing many things wrong, to the detriment of people afflicted with addiction, their families and their communities. Our mistakes are based on ignorance, misperceptions, and prejudice. All of these impede our ability to help our people with addiction. The CASA report describes these factors and how they have contributed to our present situation.
Our nation hasn’t waged a war on drugs, but rather on people who use drugs.

The CASA report describes how public opinion about addiction isn’t based on science. Science proves addiction is a brain disease, yet this fact is still debated. We know that continued use of addicting substances alters the structure and function of the brain, affecting judgment and behavior about the continued use of drugs even when bad consequences occur. We know that half of the risk for developing addiction is determined by genetic makeup. Yet surveys show that about a third of U.S. citizens still feel addiction is due to lack of willpower and self-control. Why are public attitudes so disconnected from science?

Addiction is a complicated diagnosis, existing as it does at the end of the continuum from occasional drug use to regular use to compulsive use. People often compare a drug user with a drug addict. They say that since the drug user was able to stop when he wanted that the drug addict should be able to stop when he wanted. This compares apples to oranges. If someone can comfortably stop using drugs when given a good enough reason to do so, this person isn’t an addict. They may be a drug abuser, a problem user, and at high risk for addiction, but they haven’t crossed the line into uncontrollable use.

The CASA report pointed out that most addiction treatment and prevention isn’t done by physicians and health professionals. Most addiction treatment is provided by counselors who, for the most part, aren’t required to have any medical training. Only six states require a bachelor’s degree to become an addiction counselor, and only one (Alabama, go figure) requires a master’s degree.

Even when physicians are involved in the treatment of addiction, most of us have very little, if any, training in medical school or residencies about addiction prevention or treatment. Ironically, most of our training focuses on treating the consequences of addiction.

In medical school and residency, I spent countless hours learning about the proper treatment of cirrhosis, gastritis, anemia, pancreatitis, dementia, and peripheral neuropathy from alcohol addiction. I had little if any training about how to treat alcohol addiction, and none about how to prevent it.

We know brief interventions by physicians during office visits can reduce problem drinking and are an effective way to prevent problems before they occur. Yet few physicians are trained to do this brief intervention. Even if they are trained, primary care physicians and physician extenders are being asked to do more and more at each visit with patients, and asked to do it with less and less time. Primary care providers may not be adequately paid for screening and brief intervention for problem drinking and drugging, and valuable opportunities are lost. Yet that same patient may consume hundreds of thousands of healthcare dollars during only one hospital admission for medical consequences of problem alcohol use.

When I practiced in primary care, I often thought about how I never got to the root of the problem. I would – literally – give patients with serious addiction strikingly absurd advice. “Please stop injecting heroin. You got that heart valve infection from injecting heroin and you need to quit.” I could see it was ineffective, but I didn’t know any better way at the time. I assumed if there was a better way to treat addiction, I’d have learned about it in my training.

Wrong. The doctors who trained me couldn’t teach what they didn’t know themselves.

In my Internal Medicine residency, I admitted many patients to the hospital for endocarditis (infected heart valve) contracted from IV heroin use. Each time, this required six month of intravenous antibiotics. Back then we kept such patients in the hospital the whole time. You can imagine the cost of a six week hospital stay, not that these addicts had any money to pay. Just a fraction of that amount could have paid for treatment at a methadone clinic, the most effective way to treat heroin addiction, and prevent dozens of medical problems.

But I never referred them to the methadone clinic available in that city. I didn’t know anything about methadone or the medical-assisted treatment of opioid addiction, and apparently my attending physicians, responsible for my training, didn’t know about it either. It was a shame, because in those years, the late 1980’s, we were making new diagnoses of HIV almost daily among IV drug users. Since then, a study showed a patient using IV heroin drops his risk of contracting HIV by more than threefold if he enrolls in a methadone clinic.

I didn’t learn about the evidence-based treatment of opioid addiction until I agreed to work at a methadone clinic for a few days, covering for a friend of mine when he wanted to go on vacation. I was amazed to learn about decades of evidence showing the benefits of such treatment.

Most addiction-related medical expenses are paid for from public funds. In fact, over ten percent of all federal, state, and local government dollars are spent on risky substance use and addiction problems. Sadly, over 95% of this money is spent on the consequences of drug use and abuse. Only 2% is spent on treatment or prevention.

Untreated addiction costs mightily. People with untreated addiction incur more health care costs than nearly any other group. An estimated one third of all costs from inpatient medical treatment are related to substance abuse and addiction. Untreated addicts (I include alcohol addicts with drug addicts) go to the hospital more often, are admitted for longer than people without addiction, and require more expensive heath care than hospitalized non-addicts. The complications these people suffer could be from underlying poor physical health and lack of regular preventive healthcare, but most of the cost is incurred treating the medical problems directly caused by addiction and risky substance use.

Family members of people with untreated addiction have higher health costs, too. Families of people with addiction have 30% higher health care costs than families with no addicted member. I presume that’s from the stress of living and dealing with a loved one in active addiction. Often family members are so caught up in trying to control the chaos caused by active addiction that they don’t take time for routine health visits.

The costs of untreated addiction aren’t only financial. Addiction and risky drug use are the leading causes of preventable deaths in the U.S. Around 2.9 million people died in 2009, and well over a half million of these deaths were attributable to tobacco, alcohol, and other drugs. Overdose deaths alone have increased five-fold since 1990.

We know addiction is a chronic disease, yet we spend far less on it than other chronic diseases.
For example, the CASA report says that in the U.S., around 26 million people have diabetes, and we spend nearly 44 billion dollars per year to treat these patients. Similarly, just over 19 million have cancer, and we spend over 87 billion for treatment of that disease. In the U.S., 27 million people have heart disease, and we spend 107 billion dollars on treatment.

But when it comes to addiction, we spend only 28 billion to treat the estimated 40.3 million people with addiction, and that includes nicotine!

Most of the money we do spend is paid by public insurance. For other chronic diseases, about 56% of medical expenses are covered by private payers, meaning private insurance or self-pay. But for addiction treatment, only 21% of expenses are paid from private insurance or self-pay. This suggests that private insurance companies aren’t adequately covering the expense of addiction treatment. Indeed, patients being treated with private insurance for addiction are three to six times less likely to get specialty addiction treatment than those with public insurance such as Medicaid or Medicare. Hopefully we will see a change since the parity law was passed. (which told insurance companies they had to cover mental health and substance addiction to the same degree they cover other health problems)

In the U.S., we don’t treat addiction as the public health problem that it is. Some people still don’t believe it’s an illness but rather a moral failing. Doctors, not knowing any better, often have an attitude of therapeutic nihilism, feeling that addiction treatment doesn’t work and it’s hopeless to try.

Families and medical professionals often expect addiction to behave like an acute illness. We may mistakenly think addiction should be resolved with a single treatment episode. If that episode fails, it means treatment is worthless. Families want to put their addicted loved one into a 28-day treatment program and expect them to be fixed forever when they get out. They’re disappointed and angry if their loved one relapses.

This reminds me of an elderly man I treated for high blood pressure many years ago. I gave him a month’s prescription of blood pressure medication, and when he came back, his blood pressure was good. I was pleased, and I wanted to keep him on the medication. He was angry. He said he was going to find another doctor. He thought the one prescription should have cured his high blood pressure so that he would never have to take pills again, and was disappointed with my treatment.
If we keep our same attitude toward addiction treatment, we are doomed to be as disappointed as my patient with high blood pressure. Addiction behaves like a chronic disease, with period of remission and episodes of relapse.

We have a lot of work to do. As this CASA publication shows, we have to change public attitudes with scientific information and do a much better job of training physicians and other health care providers. We should pay for evidence-based, high-quality addiction treatment, rather than spend billions on the medical problems caused by addiction as we are now doing.

Check out this landmark publication at CASA’s website: http://www.casacolumbia.org

Department of Justice Investigates Johnson City, Tennessee

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The Civil Rights Division of the U.S. Department of Justice has opened an investigation into Johnson City’s refusal to allow a methadone clinic to be located within its boundaries. According to an August newscast on Channel 11 in Johnson City, Tennessee, the city’s attorney is preparing documents to answer questions raised by the DOJ.

After the state denied the certificate of need for a methadone clinic to be opened by Tri-Cities Holdings, LLC in Johnson City, that company’s attorneys asked the Department of Justice to investigate, claiming Johnson City town officials have arranged zoning laws in a draconian way that all but eliminates the establishment of a methadone clinic.

As regular readers recall, the certificate of need for the proposed opioid treatment program was denied by Tennessee state officials this summer. In that denial, they did mention local opposition to such a program. The state also claimed that the region of Tennessee had more than enough Suboxone providers to take care of people with opioid addiction. However, there are no methadone clinics in that portion of Tennessee, one of the states with the highest per-capita opioid prescribing and per-capita opioid overdose death rates in the entire country.

The city’s attorney, Mr. Erick Herrin, thought the DOJ was looking for a “smoking gun” such as a statement by a local official that they didn’t want to treat addicts there. (http://www.wnct.com/story/23075304/jc-responds-to-federal-allegations-of-discrimination-connected-to-methadone-clinic) Mr. Herrin is quoted as saying, “ …they are not going to find that the City of Johnson City would ever intentionally look at discriminating against such a vulnerable class of people as addicts who have a disease of drug addiction. That’s not what Johnson City officials are about.”

Oh please. That statement rings false in my ears. I do not think this is the only opioid treatment program that’s been rejected by Johnson City officials. I don’t know if any Johnson City leader has ever been so misguided as to go on record with their intentions to deliberately prevent the establishment of a methadone clinic, but the leaders of another nearby Tennessee town have done so:

From the Kingsport, Tennessee Times-News, 3/18/09,
“The Church Hill Board of Mayor and Aldermen unanimously approved the first reading Tuesday of an ordinance which, in essence, makes it almost impossible for a methadone clinic to locate within the city limits.
Earlier this month, the Planning Commission recommended the ordinance, which restricts methadone clinics and drug treatment facilities to areas of the city that are zoned M-1 (manufacturing). Without the ordinance, methadone clinics and drug treatment facilities would be permitted in any area of the city zoned to allow medical uses.”
“I think we’re all in the consensus that we don’t want it anywhere,” the alderman said (name deleted). (1)
Johnson City and other small Northeastern TN towns re-wrote their zoning laws years ago, when methadone clinic owners began to express interest in establishing a clinic to serve that area’s high burden of opioid addiction. The implied intent of these zoning laws seem clear to me: prevention of establishment of a methadone clinic.

City attorney Erick Herrin says that TriCities’ attempt to involve the DOJ will back fire on them.
(http://www.wjhl.com/story/23075304/jc-responds-to-federal-allegations-of-discrimination-connected-to-methadone-clinic)

It’s hard to see how. After being soundly rebuffed by Johnson City, Tri-Cities has little to lose. Since the Department of Justice is doing the investigation, I doubt they have to spend much time or money proving their case. In an area of the country with one of the highest rates of opioid addiction, multiple attempts to open a methadone clinic have been thwarted. I think the facts speak for themselves.

I have mixed feelings about this case. At this point, I’d love for the DOJ to decide against Johnson City. They so clearly have it coming.

And I worry about the methadone clinic when it does open. After all of this hoo-ha, Mr. Kester had better take care to open the best quality methadone clinic in the entire country. If this clinic is sloppily run, it will confirm people’s bad opinions about methadone treatment. That’s quite a burden to carry and I don’t envy him his job. I’m a fierce advocate for medication-assisted treatment of opioid addiction (thus this blog) but I would not want the hassle of running a clinic in that sort of environment. Every decision the clinic makes is going to be magnified and judged harshly if something goes wrong. It only takes one public case of a misdeed by an opioid treatment program patient to skew public opinion.

For every boneheaded criminal that sells a dose of methadone dispensed by the clinic, there are a couple hundred who are quietly living better lives, freed from the demands of addiction. The public never hears about these patients. With the stigma around methadone, sometimes these patients are even afraid to tell their doctors. They look and act perfectly normal. They are your neighbors, the people that sit behind you in the bleachers at the high school ball game. You can’t tell they are on methadone because at the right dose, these patients aren’t impaired.

I feel bad for these people. How do they feel when they read the mean-spirited and uneducated comments on a website like the Johnson City press? http://www.johnsoncitypress.com/article/109952/federal-investigation-result-of-denial-of-license-to-operate-to-methadone-clinic-in-johnson-city

Patients doing well on methadone must not be made to feel like they are doing something wrong. Yet some patients feel like all the positive things they do in life: working, paying bills, paying taxes, going to church, raising children, etc., are erased in the eyes of judgmental neighbors, only because these patients chose to take a legal, medically prescribed dose of methadone every day, to block withdrawals and the obsession to want to use opioids.

It’s sad how judgmental people are, even with minds relatively uncluttered by actual facts.

1. Jeff Bobo, “Church Hill Commission Moves to Prevent Methadone Clinic” Kingsport Times-News, 3/2/09.

Heroin Invades New England

aaaaaaheroinflood

Last week the New York Times ran an article on heroin, describing how it’s infiltrated not only big cities, but also New England’s smaller towns and suburbs. http://www.nytimes.com/2013/07/19/us/heroin-in-new-england-more-abundant-and-deadly.html?pagewanted=all&_r=0
This Colombian heroin has a higher purity than users have seen in the past, meaning it can be snorted for an opioid high. Addicts who wouldn’t consider using a needle are willing to snort this heroin. And addiction being what it is, some of these addicts do eventually inject the drug.

In Maine, New Hampshire, Vermont, and Massachusetts, heroin is causing increased numbers of overdose deaths. Some experts say heroin is now being used by pain pill addicts. Since regulations around opioid prescribing have tightened, fewer (and more expensive) prescription opioid pills are diverted to the black market. Low-priced, high-grade heroin has been released into this void, creating ideal conditions for rampant heroin use. This Times article quoted law enforcement officials as saying they are seeing triple the number of overdose deaths from heroin this year as compared to several years ago.

Wow, I thought when I read the article. This is a bad situation, and it’s been brewing for years. Maine was one of the first states to see a sharp increase in opioid addiction and opioid overdose deaths around ten years ago. So of course, their conscientious state officials did the right thing, and worked together to assure evidence-based addiction treatment would be available for all who ….…oh wait. No.

No, that’s NOT what Maine’s state legislature did. In fact, they did the opposite. Duh.

Last year, Maine passed a law last year limiting Medicaid payment for treatment with methadone or buprenorphine. Against this backdrop of addiction and death, state officials decided to limit payment of treatment to two years of maintenance with either buprenorphine or methadone, and even made it retroactive to the date the patient started. After addiction medicine specialists decried the stupidity, not to mention the illegality of this, government officials backed off somewhat from their two-year limit. But the Maine legislature cut coverage and funding for opioid addiction treatment with buprenorphine and methadone in order to save money.

As I never seem to get tired of repeating: Medication-assisted treatment of opioid addiction with buprenorphine and methadone is one of the most heavily evidenced -based treatment in all of medicine.

Earlier this year, the American Society of Addiction Medicine, better known as ASAM, issued a public policy statement regarding pharmacological therapies for opioid addiction, which can be read in its entirety here: http://asam.org/advocacy/find-a-policy-statement/view-policy-statement/public-policy-statements/2013/04/25/pharmacological-therapies-for-opioid-use-disorders

ASAM’s statement says limitation of coverage for opioid addiction will cost lives. It will disrupt families and communities. It warns against limits on duration of treatment, number of times of treatment, and any other limit imposed by non-physicians on the medical care of patients with opioid addiction.

ASAM is a society of the most highly educated and experienced physicians who work in the field of Addiction Medicine. In other words, these are the best brains in the country when it comes to treatment of opioid addiction that exists in our nation. One would think that federal, state, and local governments would pay attention to what they had to say. One would think insurance plans would do the same.

The federal Mental Health Parity and Addiction Equity Act, passed in 2008, was intended to entitle patients with mental illness and substance abuse issues the same medical coverage as patients with other illnesses. Clearly the Act is being violated in Maine and other states, but so far the federal government hasn’t enforced the law.

I rarely advocate for the involvement of lawyers into any situation, as they can complicate the simplest of situations. However, here’s a situation ripe for picking. It’s going to take legal action by patients who have been denied federally mandated medical coverage to get the attention of insurance payers. This is against the law. This includes federal and state coverage as well as private insurance, because all have put some limits on coverage of the treatment of addiction.

It’s important to try to educate state legislators and to let them know you are watching to see if they are doing the right thing. But when they don’t do the right thing, maybe it’s time to call in the lawyers.

Important Meeting In Tennessee!

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Educated and informed people have an opportunity to make an impact on the life expectancies of opioid addicts in Eastern Tennessee!

The Tennessee Health Services and Development Agency is holding a fact-finding public hearing, regarding the certificate of need application for a methadone treatment facility, proposed to be located in Johnson City, Tennessee.

This meeting will be held on May 28th, 5pm, in the Jones Meeting Center, Johnson City Public Library, on 100 West Millard Street in Johnson City, Tennessee.

There’s a desperate need for medication-assisted treatment of opioid addiction in that part of Tennessee. Opioid addicts can get treatment in office-based Suboxone practices now, but as discussed in previous entries on this blog, this can be an expensive treatment. Many addicts don’t have insurance to pay for this treatment, which is then out of financial reach. For other addicts, buprenorphine, being a partial opioid, isn’t strong enough. Methadone can work beautifully for patients who don’t do well on buprenorphine (known to most as Suboxone or Subutex). However, there are no methadone treatment programs in Eastern Tennessee, so a clinic in that area is desperately needed. The nearest in-state clinic is in Knoxville.

People who know methadone works and saves lives need to go to this meeting to be heard. I suspect there will be people there who know next to nothing about methadone who are nonetheless opposed to a clinic. We’ve all met them: people adamantly opposed to methadone even though their brains are uncomplicated with any actual knowledge of methadone. And there will the NIMBYs, the not-in-my-backyard people.

Citizens who know there are scientific studies showing that methadone is an evidence-based treatment shown to save lives need to go and be heard. Tell other people at the meeting about the forty years’ of studies consistently showing that methadone maintenance reduces overdose death rates, improves overall physical and mental health, increases rates of employment, reduces the risk of suicide, dramatically reduces criminal activities of opioid addicts (by a whopping 91%), and reduces the rates of new cases of HIV.

It’s hard to imagine the certificate of need could be denied, but remember attempts to locate a methadone treatment center in Eastern Tennessee have tried – and failed – ten times before. Let’s hope science and reason can win over ignorance and prejudice.

If, like me, you can’t make the meeting, please send a letter to:

Tennessee Health Services and Development Agency
Melanie M. Hill, Executive Director
Frost Building, 3rd floor
161 Rosa Parks Boulevard
Nashville, TN 37243

Update on the State of Denial: Is the Tide Finally Turning?

Word -HELP with syringe on white pills.

After my last post, I heard from Steve Kester, the co-owner and manager of the company seeking to open an opioid treatment program in Johnson City, Tennessee. He’s had great news: the certificate of need was approved. In addition, he was invited to write a Sunday editorial in the Johnson City Press, correcting mistaken information and explaining more about how an opioid treatment program works.

It’s a great article, and you can read it here: http://www.johnsoncitypress.com/Opinion/article.php?id=105510#axzz2PxuPsb4q

Granted, it’s still posted in the paper as an opinion piece, though every bit of data he describes is science, proven in multiple studies. That’s much more than an opinion. But still, it’s progress for the paper to print this side of the treatment issue.

In the article, Mr. Kester makes several points that should clear misunderstandings people have about methadone clinics. He describes how methadone is not the same thing as methamphetamine, even though both words begin with M-E-T-H. It is still surprising how many people don’t know the difference. He also talks about how an opioid treatment program is not a pill mill but exactly the opposite of a pill mill. He outlines the benefits to the community when opioid addiction is treated. Instead of 80% of opioid addicts committing crimes to support their addiction, 80% of addicts enrolled in medication-assisted treatments are employed and are productive members of society. He reminds us that many Iraq/Afghanistan war vets are among the addicts seeking treatment for their pain pill addiction. Also, he agrees that opioid treatment programs should not be located in residential areas, and his program will not be located in a residential area.

Towards the end of the article, Mr. Kester reminds readers that denying access to care for people who are sick with addiction is illegal, a violation of federal law, since addiction is covered under the Americans with Disabilities Act of 1973.

He was polite in his article, but I would add that if Johnson City throws up unreasonable roadblocks, it’s likely the town will be sued in federal court. If so, they are sure to lose, given recent cases setting precedent. Awards have been in the high six-figures, so citizens of Johnson City and their local government representatives should think hard about whether it’s worth it break the law to prevent addicts from getting evidence-based treatments.

There’s a mischievous part of me that hopes a town in Tennessee – again, for the eleventh time – breaks the law and denies treatment by blocking the opening of an opioid treatment center. It would amuse me greatly to see town officials get the pants sued off of them. But that’s not in the best interests of people suffering from addiction. Hopefully this opioid treatment program can be opened forthwith.

Just another reminder to write to this address to support opioid addiction treatment with medication-assisted therapies:
Health services and Development Agency
The Frost Bldg 3rd Floor
161 Rosa Parks Blvd
Nashville, TN 37243

The State of Denial (Tennessee) gets Another Chance

aaaprejudice and ignorance

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. [1]

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

1.http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6043a4.htm?s_cid=mm6043a4_w
2.http://international.drugabuse.gov/sites/default/files/pdf/methadoneresearchwebguide.pdf
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
4.http://www.asam.org/docs/publicy-policy-statements/1methadone-rev-10-061.pdf?sfvrsn=0#search=”methadone

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