Important Meeting In Tennessee!

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?

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

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

Kafkaesque

Quackery

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Once again, Tennessee’s Department of Mental Health and Substance Abuse Services has managed to bitch slap science in the face.

Yesterday I asked a knowledgeable friend what he knew about Tennessee’s final version of the Opioid Treatment Program regulations, and he sent me a file containing the final revisions. The document also records commentary and objections of various stakeholders (trendy term for, “the people who are really affected”). I read this material late last night, and went to bed feeling depressed and defeated.

This morning, I reflected on the progress of science. Particularly in the field of medicine, we’ve made great strides, largely after the advent of the scientific method of clinical trials. Before we knew how to test different treatment methods in clinical trials, medical treatment of illness in the U.S. depended on the individual doctor’s anecdotal experiences with patients, and traditional healing methods. When asked why they used leeches and bloodletting, the doctor would say “Because that’s the way we’ve always done it.” Doctors did the best they could with limited scientific data.

In the early part of the twentieth century, European scientists and research doctors began using scientific methods to determine which treatments really worked. These methods included the use of randomized trials comparing one treatment to another, and the use of statistics to analyze results. As a result, medical knowledge and practice advanced rapidly in Europe, and the U.S. medical establishment lagged far behind. U.S. medical schools and the doctors they produced began to have terrible reputations worldwide.

Appalled at the poor quality of care provided by many practicing physicians in the U.S., the Carnegie Foundation asked a group of scientists to investigate what should be recommended to bring the U.S. up to date with the rest of the world. The result of this mission was contained in the “Flexner Report,” written by Dr. Abraham Flexner.

The Flexner report was a great document. It outlined in great detail the failings of U.S. medical schools and medical establishment. At that time, 1910, many schools were for-profit affairs owned by a few physicians more interested in collecting tuition than teaching accurate material. Much of what young doctors were taught was outdated and inaccurate. The Flexner Report stated what doctors at the few good medical schools already knew: many poorly trained doctors throughout the U.S. offered so-called cures with little or no evidence to support their treatments. Citizens were not getting scientifically-based treatments then available in other parts of the world.

As a result of this report, many deficient medical education programs were shut down. Flexner recommended that only medical schools whose teachings adhered to the accepted scientific method should be allowed to remain open. Because of the Flexner report and the actions taken based on its findings, scientific method eliminated the quackery that was popular in the U.S. in the early 1900’s. The United States followed the recommendations of the Flexner Report, and now U. S. medical care and research meets or exceeds standards in other countries.

But in Tennessee, the leeches are back.

From four decades worth of research into the treatment of opioid addiction with methadone, we know what works and what doesn’t work. We have a coherent, evidence-based body of knowledge surrounding best practices for the treatment of opioid addiction with methadone. Numerous agencies have produced documents containing evidence supporting the use of methadone maintenance in the treatment for opioid addiction: National Institutes of Health, Center for Disease Control and Prevention, Institute of Medicine, National Institute of Drug Abuse, Center for Substance Abuse Treatment, and Substance Abuse and Mental Health Services Agency.

Great summaries of this data are easily available in several places: NIDA’s wonderful website at http://international.drugabuse.gov has all the answers to most questions, and references (studies done with scientific method) to support the data. SAMHSA published – for free to anyone who wishes a copy – the Treatment Improvement Protocol 43, often called “TIP 43” for short. To point out the obvious, treatment of a medical illness shouldn’t be decided by how one “feels.” about the treatment. It should – of course – be based on the best science. In response to many of the odd regulations proposed by Tennessee’s Department of Mental Health, many respectable organizations weighed in with their concerns. Usually, they cited data to back up what they claimed was the current, state-of-the-art practices for methadone maintenance treatment of opioid addiction. Groups included not only the present treatment programs currently operating in Tennessee, but also the American Association for the Treatment of Opioid Dependence (AATOD), the National Alliance for Medication-Assisted Recovery (NAMA),

To be fair, the state did acknowledge and change some of their rules on minor things. But when confronted with data that proves their regulations are not best practice, the Tennessee Department of Mental Health basically said, “We disagree.” In other words, “We don’t need no stinkin’ science to tell us how to do things! We know what’s best!”

I can’t stand to go into detail about all the ways in which Tennessee goes back into the dark ages, but here are a few of the most imprudent regulations:

• Before being allowed into methadone treatment, a new patient must have two years of physical dependence, unless they’ve had a failed abstinence-based treatment attempt and one year of physical opioid dependency.

My beef with this is: we know patients on waiting lists for methadone die at eight times the rate of patients enrolled in methadone treatment. Is Tennessee just hoping addicts will die off ? Also, has Doug Varney (head of the state methadone authority in Tennessee) ever tried getting an opioid addict with no money and no insurance into an abstinence-based Tennessee treatment program lately?

• The state methadone authority needs to be notified of patients going to doses higher than 100mg
• No patient can go over 120mg unless first given permission by the state methadoneauthority.

OK, so a non-physician is going to make a medical decision? That sounds like practicing medicine without a license to me…isn’t that a felony? Maybe it’s only a misdemeanor in Tennessee. Seriously, what qualifies a state administrator to make any decisions about the dose of any medication? They have no way to talk to the patient, no way to examine them to get clinical information. Does a pharmacist working as the head of the state’s mental health administration have the experience or knowledge, let alone the authority, to decide the doses appropriate for patients?

Even putting aside the suffering this inane rule will bring to patients, what about the legal implications for the person making these decisions at a state level? What non-doctor would be foolish enough to go on record denying a dose of medication that a doctor thought necessary? It seems like a situation ripe for a lawsuit. Consider the following scenario: patient needs dose increase because she is still having significant withdrawal. Doctor at OTP examines her, makes the clinical decision that she needs a higher dose of methadone. State office worker denies permission for the dose increase. Patient leaves treatment, frustrated that she’s still in opioid withdrawal and can’t become stable. A few weeks later, she dies from a fatal illicit opioid overdose.

Usually I eschew lawyers, since they can complicate a one-car funeral procession, but wouldn’t this be a winnable legal case for the family? But for the interference of the state office worker, the patient may not have dropped out of treatment and died from untreated opioid addiction. And what if the office worker approved the increased dose, and the patient died from a methadone overdose? Is the state, since they approved the increased dose, at risk for any bad outcome that results from the dose increase?

• With one positive urine drug screen, patients get no take homes for 30 days, and have to do mandatory weekly counseling.

I like the idea of more counseling, but weekly may be difficult for working patients, and we do want them to be able to keep their jobs, right? That is one goal of recovery, right? Besides, removing take homes after only one positive is simply punitive unless there’s imminent danger of overdose.

• With the fourth consecutive positive urine drug screen within six months, more intense counseling is mandated. Intensive outpatient and residential treatment are listed as options. And if the patient refuses these options, he will be terminated from the opioid treatment program.

I can barely stand to list all the reasons this is a miserable decision. First of all, have you ever tried to get a patient on methadone into a Tennessee Intensive Outpatient Program or residential program? All the ones I’ve dealt with say they must be off methadone before entering, so this is all very Kafkaesque.

In fact, Tennessee’s state methadone authority is Kafkaesque (“Instances in which people are overpowered by bureaucracies, often in a surreal, nightmarish milieu which evokes feelings of senselessness, disorientation, and helplessness.”) [1]

As I said, I’m depressed by the thought of how thoroughly Tennessee’s ignorance has managed – yet again- to bitch slap science in the face.

I think I’ll go back to bad.

1. Wikipedia, 10/17/2012   http://en.wikipedia.org/wiki/Franz_Kafka

Pregnant Women Using Drugs

Pregnant addicts are the most stigmatized group in U.S. society. Even other drug addicts regard pregnant addicts with scorn. But the nature of addiction is the loss of control – pregnant addicts usually do want to stop using drugs, but have lost the power to do so without help. And even if they do seek help, pregnant women face special barriers to proper care. The stigmatization alone is enough to keep many women from getting help. They face overwhelming shame and blame from society and from their own families. Pregnant women don’t tell their obstetricians about their addiction, for fear they will be treated harshly by the professionals on whom they must depend to deliver medical care. I’ve already blogged about the atrocious misinformation some obstetricians accept as true about opioids addiction and treatment during pregnancy.  Female addicts, scared and ashamed to ask for help, try to hide their addiction as well as they can, and hope for the best.

If a pregnant addict does seek help, many treatment programs won’t accept her into treatment, because she is too high risk. Addiction treatment programs sometimes don’t want the liability of a pregnant addict.

At one of the opioid treatment programs where I used to work, a woman came for admission in her fifth month of pregnancy. I tried to be gentle as I asked her why she’d waiting so long to get help. She laughed without humor and told me she’d been turned away from three other treatment facilities. The first was an inpatient residential treatment program that turned her away because she was addicted to opioids. They told her if they took her into their treatment program, she would have to undergo withdrawal, because they did not “believe” in methadone or buprenorphine (Subutex). And if she went into withdrawal, she could miscarry.

They directed her to an inpatient detoxification program that also declined to admit her because they didn’t want her to miscarry while in their facility. They (correctly) referred her to an opioid treatment program. The first opioid treatment program offered only methadone, and since she preferred buprenorphine, they referred her to the clinic where I worked. This patient had (correctly) heard new studies showed less severe withdrawal in babies born to moms on buprenorphine (Subutex) compared to moms on methadone.  That clinic then referred her to our clinic, since we do use buprenorphine. All of this took a few weeks, delaying her entry to treatment. The treatment programs made the right decisions, but addiction treatment is so patchwork that it took time for her to ping-pong from place to place until she found the treatment she needed.

Pregnant women fear they will lose custody of their children if they admit to being addicted and ask for help. Sadly, in some counties in my state, their fear is well-grounded. Some women are told they will lose their children because they have enrolled in medication-assisted treatment with methadone or buprenorphine, even though it’s the treatment of choice for opioid-addicted pregnant women. In most cases, treatment center staff can act as advocates, and talk to social service workers who may not be well-informed about addiction treatment. Punishing a mom for getting help doesn’t help anyone. Word spreads in addict social networks, making other women less likely to get help for addiction.

Often, the pregnant addict’s husband or partner is also addicted. He may try to keep her away from drug addiction treatment, fearing loss of control over her, or he may feel like he’ll be asked to stop using drugs too. Even if she’s able to go to treatment, having a drug-using partner makes it more difficult to stop using herself.

Women, pregnant or not, tend to have childcare issues. If they want to get help, who will watch the children while they attend treatment?

Despite the difficulties faced by pregnant addicts, most want desperately to deliver a healthy baby. We know from several studies that harsh confrontation predicts addiction treatment failure in pregnant women. That is, if treatment facility personnel, obstetricians, nurses or any other member of the treatment team tries to blame and scare a pregnant addict into stopping drug use, it backfires. Pregnant women tend leave treatment when they are treated harshly, and have worse outcomes than women who stay in treatment.

I’ve written blogs about the negative attitudes some medical professionals have toward pregnant opioid addicts who come for treatment with buprenorphine (Subutex) or methadone. Thankfully, that’s not a universal attitude. Recently an obstetrician referred her patient to us, calling ahead to speed things along. I called her back after I saw the patient, and we had a cordial conversation which I appreciate all the more in view of negativity I’ve experienced in the past.

I thought again about the topic of opioid-addicted pregnant addicts because of an article in my most recent issue of Journal of Addiction Medicine. This article described the outcome of a study of opioid-addicted pregnant patients in rural Vermont. Since methadone and buprenorphine (Subutex) are the treatments of choice for these patients, the study looked to see if better access to these treatments improved outcomes. The results showed, not surprisingly, improved access to medication-assisted treatment for opioid addiction in pregnant addicts improved the health outcomes for both mothers and babies. Earlier research showed the same result, but this was a rural group, underrepresented in past studies.

Meyer, M, et. al, “Development of a Substance Abuse Program for Opioid-Dependent Nonurban Pregnant Women Improves Outcome,” Journal of Addiction Medicine, Vol. 6 (2) pp.124-130.

Tennessee’s Vision for Mental Health

“Prejudice is a great time saver. You can form opinions without having to get the facts.”   E. B. White

You’d think I’d get tired of bashing Tennessee’s Department of Mental Health, but nope, not yet. That agency is like popcorn stuck between my teeth. It’s so annoying.

Mr. Doug Varney, the new leader of Tennessee’s Department of Mental Health, has a negative opinion of medication-assisted therapies, as I’ve discussed in prior blog entries.

Among his misconceptions, he’ made some curious statements about the for-profit status of opioid treatment programs seeking to open programs to treat Tennessee’s mass of opioid addicts.

According to the Kingsport Times-News, Mr. Varney said, “All the financial incentives are for them to keep people maintained on methadone as opposed to being drug-free,” he said. “I have a problem when I read the applications and one of the goals of the program that measures their outcome is that the person will still be coming to the clinic two years later. There’s no detox there.”  (1)

Yet as reviewed in my previous blog entry, the American Society of Addiction Medicine’s position paper on the use of methadone to treat addiction says quite the opposite, recommending …“Discontinuation of methadone maintenance should be attempted only when strongly desired by the rehabilitated patient…” and “Arbitrary caps on the number of patients who can be treated by a physician, the dosage of medication which is allowed, or the duration of treatment with methadone are not supported by medical evidence and should not be imposed by law, regulation, or health insurance practices.” (2)

ASAM is made up of physicians who specialize in treating addiction. They are the most knowledgeable doctors in the nation about addiction and treatment. For all other diseases, this would qualify them to set treatment standards.

Not in Tennessee.

In Tennessee, Mr. Varney’s personal opinions override evidence-based medical treatment. It’s a triumph of ideology over medicine, and it adversely affects opioid addicts all across Tennessee. This is something that would not be tolerated in any other field of medical care.

It sounds like Mr. Varney thinks addiction treatment facilities should be non-profit, to remove the financial motive for treatment. If so, I don’t necessarily disagree with him, but it would be an unusual position for an appointed public official to take in Tennessee, a state with a Republican governor.

Right now, medical care is a business in the U.S. I’m not particularly happy about that, and have my own opinions, but that’s the current state of affairs in this country. There’s no reason why the treatment of addiction is any different than the treatment of any other disease. For-profit companies own hospitals, doctors’ offices, x-ray facilities, nursing homes, and so on. Therefore Mr. Varney’s protestations about for-profit facilities make no sense given the realities of medical care in the U.S. today.

Besides, I’ve personally worked for one non-profit opioid treatment center, and four for-profit opioid treatment centers. The non-profit clinic didn’t give the best care of the five. At least two of the for-profit clinics gave better care, so I don’t think it necessarily helps the patients to go to a non-profit opioid treatment program, unless they have some sort of government funding. And then the care may be more affordable, not necessarily better.

Mr. Varney should be grateful for any opioid treatment program, non-profit or for-profit, willing to open a facility in his state. I can only imagine how difficult it is for the existing opioid treatment programs in that state, subjected to regulations that fly in the face of good patient care. Not to mention that every dollar these self-pay patients spend on medication-assisted treatment would save Tennessee taxpayers a minimum of $4 in expenditures, mostly in reduced incarceration expenses and reduced healthcare costs. (3)

1. http://www.mapinc.org/drugnews/v04/n1408/a02.html
2. http://www.asam.org/docs/publicy-policy-statements/1methadone-rev-10-061.pdf?sfvrsn=0#search=”methadone“
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

Epic Fail: Tennessee’s Department of Mental Health

I admit I’ve been a little obsessed with Tennessee’s misguided approach to treating opioid addiction. It sticks in my craw. I can’t get over how backward their attitudes and approaches to the treatment of prescription opioid addiction have been, and I’m struggling to find out why Tennessee is the way it is. I hate bad science and ignorance. It grieves me to see the senseless suffering of the state’s addicted citizens.

I’ve been combing the internet and have found information that makes my right eyelid twitch. In the January 28, 2012 issue of the Tennessean, (1) Doug Varney is named as the new head of Tennessee’s Department of Mental Health. According to this article, he says Tennessee’s opioid treatment programs should to do a “better job” of weaning people off methadone and into detoxification programs. He says there’s no evidence to show methadone helps pain pill addicts as it does heroin addicts. He feels there are more appropriate treatments. In the past, Mr. Varney has been on record as saying methadone doesn’t accomplish anything because it’s merely switching one drug to another.

Yikes. This shows he understands about as much as the person who says methadone is “like giving whiskey to the alcoholic.” I’m not surprised when an average person says such things, because most people don’t know much about methadone, and are misinformed. But this person is the head of Tennessee’s Department of Mental Health!

I suspect he’s also behind the new proposed rules for Tennessee’s opioid treatment centers. Some of the proposed rules are good, and deal with quality of care. And others are harmful, and contradict what we know to be good medical practice.

For example, the new rules say an opioid addict needs to fail at two attempts at drug-free treatment before being allowed to enter an opioid treatment program. Where’s the science to back up that position? There is none. I challenge Mr. Varney to produce evidence showing two attempts at drug-free treatment do anything to help the addict. We know with detoxification alone, relapse rates are consistently in the range of 92-98%. We’ve known this since the old days at the Lexington, KY Narcotic Farm, established in 1935. The data are unchanged today with pain pill opioid addicts.

Besides, where will Tennesseans get this drug-free treatment? I’ve tried, and watched addition counselors try for hours to get opioid addicts into drug-free treatment in Tennessee. On the rare occasions when I’ve seen an opioid addict from Tennessee for whom methadone isn’t the best treatment, it’s next to impossible to find an inpatient treatment center eager to admit this patient. Even if there’s no waiting list for beds, the patients don’t have the money to afford it. And if state money pays for treatment, opioid addicts are rarely kept long enough to really help them. As above, short inpatient admissions accomplish little besides just detoxification, and that’s insufficient. With opioid addiction, patients need more than a month-long admission if drug-free treatment is undertaken. Otherwise it’s a waste of time and money,  sets the addict up for failure. and their family for disappointment.

The proposed rules say that after four positive urine drug screens within six months, the patient on methadone maintenance should be discharged from treatment. Are you kidding me? That runs counter to good medical practice.

Of course, people could say I’m biased because I make my living treating opioid addicts. OK, don’t take my word for it. Let’s consult the American Society of Addiction Medicine, the nation’s most prestigious group of medical doctors, educated and dedicated to the treatment of addiction. The Society has a position paper regarding methadone maintenance which says,

 “Discontinuation of methadone maintenance should be attempted only when strongly desired by the rehabilitated patient…” (2) ASAM’s paper correctly explains the high risk of death for a patient discharged from methadone maintenance. The literature shows death rates for patients who leave or who are terminated from opioid treatment programs spike significantly, to at least eight times the rate of patients who stay in medication-assisted treatment.

Another ill-advised new rule says that permission must be granted for doses higher than 120mg, and the state methadone authority must be notified for any dose rising about 100mg. Again, what does the evidence show? Let’s go to ASAM’s position paper: “Arbitrary caps on the number of patients who can be treated by a physician, the dosage of medication which is allowed, or the duration of treatment with methadone are not supported by medical evidence and should not be imposed by law, regulation, or health insurance practices.” Their position paper is backed by numerous study citations, and thus based on solid eveidence, not personal feelings.

In other words, the addiction medicine physicians have warned against the very actions that Mr. Varney is proposing. ASAM says it’s bad medical practice. They are physicians. Mr. Varney is not.

Mr. Varney needs to realize how serious this is. These proposed new rules for opioid treatment programs have the potential to further increase Tennessee’s opioid overdose death rates. It’s high enough as it is, as 13^th highest in the nation. And remember from my past blogs, Tennessee is second highest in the nation for number of opioid prescriptions written, adjusted for population.

How did this guy get into a position of such power? What a disaster! State officials with this kind of authority to impact the lives of citizens have a moral obligation to do what’s best for citizens. Clearly, Tennessee’s Department of Mental “Health” is allowing personal prejudice to get in the way of sound medical practice. Is this even legal?? It makes me wish I lived in Tennessee, if only to vote against whichever administration selected this man to run the state’s Department of Mental Health.

There are actions we can take. Write to Mr. Varney and let him know you don’t think he should propose legislation for actions that knowledgeable physicians have deemed bad medical practice.

Here’s the mailing address:

Tennessee Department of Mental Health
Central Office
11th Floor, Andrew Johnson Tower
710 James Robertson Parkway
Nashville, Tennessee 37243
(615) 532-6500

Or, even quicker, send an email: OCA.Tdmh@tn.gov

Join with other advocates of appropriate, evidence-based medication-assisted treatment at the website of the National Alliance of Medication Assisted Recovery. You’ll see on their homepage that Tennessee is at the top of the list of their advocacy concerns: http://www.methadone.org/  They have some alternative email and regular mail addresses that may work better than the ones above.

1. http://www.tennessean.com/article/20120128/NEWS07/301280024/TN-methadone-clinics-could-get-new-rules
2. http://www.asam.org/docs/publicy-policy-statements/1methadone-rev-10-061.pdf?sfvrsn=0#search=”methadone“

Tennessee: Epic Fail?

In my last blog, I wrote about information regarding prescription opioids released last fall by the Centers for Disease Control and Prevention. This information gives states’ data for both number of overdose deaths per capita and kilograms of opioids prescribed per capita. Though Tennessee had the 13^th highest overdose death rate in the nation, it was the second highest in amount of opioid prescribed per capita, with 11.8 kilograms of opioids prescribed per every 10,000 people.

By the way, North Carolina had a prescription rate of 6.9 kilograms per 10,000. This means that doctors in North Carolina prescribe only around fifty- eight percent of what doctors in Tennessee do, adjusted for population.

We know that areas with more prescribed opioids have higher addiction and overdose death rates than areas with lower rates of prescribed opioids. That’s clear not only from the CDC data, but also with what we know from other studies of addictive drugs.  Any time an addictive substance is more available, more people become addicted. This holds true from prescribed medication just as it does for illicit drugs and alcohol. Just from the CDC data alone, it seems apparent that Tennessee has a big problem with pain pill addiction.

Now let’s look at the treatment options for opioid addicts. The best treatment outcomes for opioid addicts are consistently seen with medication assisted treatment with buprenorphine (Suboxone) or methadone.

Other treatment approaches can work, such as medical detoxification followed by at least one month of inpatient residential drug addiction treatment. Better results are seen with longer residential treatments, but inpatient options are often not attainable from the working poor, who are uninsured or underinsured. Therapeutic communities, where the addict lives and works in a community of recovering people, and also receives addiction counseling, can work for those people who can take eighteen months out of their lives for treatment.

And we know what doesn’t work. Putting addicts in jail doesn’t work. If it did, we would have been curing addiction since the 1950’s, when incarceration was first put forward as a solution to the addiction problem.

Inpatient detoxification alone does not work. Relapse rates for opioid addicts, in study after study, are consistently in the 90 to 96% range, and most of these relapses are within the first month. Yet in many communities, the same addicts are cycled in and out of detox, and then blamed because they couldn’t stay clean, even though we know they had less than a 10% chance of being successful.

Medication-assisted treatment with buprenorphine and methadone work well, and work quickly. These approaches are more acceptable to the addicts, and much more affordable, at least in the short-term. We know such treatment saves lives, reduces drug overdose deaths, reduces infectious diseases like HIV, reduces suicides, reduces crime, and improves overall physical and mental health.

But Tennessee has only ten opioid addiction treatment programs in the entire state to serve its present population of 6.3 million. And remember these folks have almost twice the opioids than their North Carolina neighbors. North Carolina, with a population of 9.5 million people, has forty-five opioid addiction treatment programs, ready to treat opioid addicts with the best evidence-based treatment available.

Using present estimates of the numbers of opioid addicts who need treatment, even North Carolina doesn’t have enough space in their opioid treatment programs to treat them all. But then, not all of the addicts want help. Tennessee doesn’t even come close to having adequate, evidence-based treatment available for its citizens who become addicted to pain pills. Thankfully, Tennessee does have buprenorphine (Suboxone) doctors, and the http://buprenorphine.samhsa.gov website lists 292 of them. But each doctor can have only up to either 30 or 100 patients per doctor.

Why has this state, which obviously has one of the worst prescription opioid addiction problems in the entire nation, consistently opposed evidence-based treatment for opioid addiction? Sadly, it’s probably the usual culprit: stigma. Even the officials at Tennessee’s department of health and human services must not be educated and informed about which treatments work the best for opioid addicted people.

If I lived in TN, I’d be fighting mad. Actually, I’m already angry, because I see desperate Tennessee pain pill addicts driving from Tennessee to North Carolina for help. I work at a clinic in the mountains of North Carolina, and see patients driving an hour or more to get the help that should be available to them in their home state. I don’t mind. I’m glad to see them, and glad to help them. Almost without fail, they’re really nice people, the kind you’d enjoy having as a neighbor. But too many times I see these people have to leave a treatment that’s working for them because they can’t practically travel that far every day to get their dose of medication.

If I lived in Tennessee, I’d demand that my state officials get their heads out of the sand, and do something to bring their raging pain pill addiction epidemic under control. I’d write the governor, senators, and state representatives. I’d ask why Tennessee’s Division of Alcohol and Drug Abuse Services appears to be indifferent to perhaps the biggest public health issue of our times. If I didn’t get satisfactory answers, I’d be sure to remember and vote accordingly in the next election. Nothing gets a politician’s attention like threatening not going to vote for them.

I might make some noise at a local level, and ask local officials why their communities have refused to allow treatment centers in a state that desperately needs them. Maybe I’d try to organize a group of concerned citizens at the grassroots level. Perhaps larger national organizations like NAMA (National Alliance for Medication-assisted Recovery) could assist.  You can find them at http://www.methadone.org/  And if you go to that website, you’ll find that Tennessee is their number one most important issue, because of the non-evidence-based proposed new regulations on existing opioid treatment programs. NAMA’s website has an address for concerned Tennessee citizens to send mail protesting the proposed regulations. You could also voice your opinion about the need for more treatment centers to help addicts.

But we know treatment centers will never be the whole answer to the problem of addiction. Tennessee, like other states, will need a variety of efforts to solve their problem.

A comprehensive solution will involve things like:

• Better physician education in medical school, residency, and private practice about addiction and its treatment. Doctors need to know how to prescribe opioids more safely, with proper monitoring. State medical boards need to be clear about prevailing standards for prescribing such medications.
• Physicians need to make use of important tools like prescription monitoring programs.
• Drug courts need to be expanded, and need to accept patients on medication-assisted treatments.
• Citizens need to realize they should not share medications with friends and family, both because it could be harmful and because it’s against the law.
• Legal action against pill mills. To determine if a pain practice is legitimate or not, allow other physicians to review charts. Other physicians are better trained to do this than law enforcement.
• Citizens need to make sure all medication is stored securely and out of the reach of children and even adolescents, who often get medications from the adults in their lives.

Consider letting your Tennessee officials know what you think of the job they’ve been doing

New Controls on Opioid Prescribing

As discussed in my last blog entry, prescription monitoring programs will help diminish our present-day epidemic of prescription opioid addiction, but these PMPs are just a start. State and federal governments are passing other laws, with the intent to reduce pain pill addiction.

For example, over the summer, Ohio enacted legislation aimed at physicians who primarily see patients prescribed opioids for chronic pain. Doctors prescribing opioids for more than 50% of their patients are now required to take periodic continuing medical education classes about the safe prescribing of opioids. These physicians are required to take a minimum of twenty hours of training every two years. Ohio also now says that physicians who own pain practices need to register with their medical board and undergo site inspections, as well as comply with patient-tracking requirements. Six other states now mandate doctors get yearly continuing education on pain management and the safe prescribing of opioids to maintain licensure from their medical boards.

Some doctors protest these measures, but this training is intensely needed. More than ten years ago, CASA (Center on Addiction and Substance Abuse at Columbia University) did a study that showed physicians are poorly trained to recognize and treat addictive disorders. Of doctors who were surveyed about the training they received in their residency programs, thirty-nine percent received training on how to identify drug diversion, and sixty-one percent received training on identifying prescription drug addiction. Seventy percent of the doctors surveyed said they received instruction on how to prescribe controlled substances. (1)

These findings are appalling. Thirty percent of doctors received no training on how to prescribe controlled substances in their residency programs.  Nearly a third of the doctors leaving residency – last stop for most doctors before being loosed upon the populace to practice medicine with little to no oversight – had no training on how to prescribe these potentially dangerous drugs. Sixty-two percent leaving residency had training on pain management. This means the remaining thirty-eight percent had no training on the treatment of pain.

 These doctors weren’t in specialty care. They were in family practice, internal medicine, OB/GYN, psychiatry, and orthopedic surgery. The study included physicians of all ages (fifty-three percent were under age fifty), all races (though a majority at seventy-five percent were white, three other races were represented), and all types of locations (thirty-seven percent urban, thirty percent suburban, with the remainder small towns or rural areas). This study shows that medical training in the U.S. does not, at present, do a good job of teaching doctors about two diseases that causes much disability and suffering: pain and addiction.

 Despite having relatively little training in indentifying and treating prescription pill addiction, physicians tend to be overly confident in their abilities to detect such addictions. CASA found that eighty percent of the surveyed physicians felt they were qualified to identify both drug abuse and addiction. However, in a 1998 CASA study, Under the Rug: Substance Abuse and the Mature Woman, physicians were given a case history of a 68 year old woman, with symptoms of prescription drug addiction. Only one percent of the surveyed physicians presented substance abuse as a possible diagnosis.  In a similar study, when presented with a case history suggestive of an addictive disorder, only six percent of primary care physicians listed substance abuse as a possible diagnosis. (2)

Besides being poorly educated about treatments for patients with addiction, most doctors aren’t comfortable having frank discussions about a patient’s drug misuse or addiction. Most physicians fear they will provoke anger or shame in their patients. Physicians may feel disgust with addicted patients and find them unpleasant, demanding, or even frightening. Conversely, doctors can feel too embarrassed to ask seemingly “nice” people about addiction. In a CASA study titled, Missed Opportunity, forty-seven percent of physicians in primary care said it was difficult to discuss prescription drug addiction and abuse with their patients for whom they had prescribed such drugs.

From this data, it’s clear physicians are poorly educated about the disease of addiction, as well as the safe treatment of pain. Medical schools and residencies need to critically re-evaluate their teaching priorities to include training in pain management and addiction. Until that can be done, states need to mandate yearly training for physicians on these topics, because most practicing physicians never got adequate training on these topics.

Most doctors are not happy about these government mandates. It’s human nature to resent being told you need more training, especially if it’s at your own expense. It’s difficult to get time off work for trainings and it’s inconvenient. Yet the alternative – no increase in training for practicing physicians – isn’t acceptable. The addiction rate is too high in this country to ignore, or to avoid taking actions.

Not all of the new state mandates are good ideas.

The state of Washington passed a law in 2010 that took effect in July of this year. It says only pain management specialists can prescribe more than the equivalent of 120mg of morphine per day for a patient. Non-pain management doctors cannot prescribe more than this, by law.

I think it’s alarming when lawmakers set dose limits for any medication. I don’t know of any other medication in any other state that has a dose limit set by non-physicians.

I assume Washington’s lawmakers had good intentions. They’re concerned about the rising numbers of opioid overdose deaths in their state. They based the cut-off of 120mg of morphine on a study (Annals of Internal Medicine, Jan 19, 2010) that showed patients taking more than 100mg of morphine, or its equivalent, were nine times more likely to have a drug overdose than those prescribe 20mg or less. But these lawmakers aren’t equipped to understand the real life complications that may occur due to this law. Government officials have already admitted they don’t know how patients will be able afford to see pain specialists, or even be able to find a specialist, since there aren’t enough pain specialists in that state. The government’s website explaining the new rules (3) also admits there are no lists of physicians pain specialists. I couldn’t find the state’s definition of a “pain specialist” on this website, so there will be confusion as to what this even means. If it means only doctors who are board-certified in pain management, that will surely be a very small number. Some doctors have said they will avoid prescribing opioids at all, given the additional regulatory burdens.

Other critics of this new law say it gives false gives reassurances to patients and doctors that doses under the 120mg cutoff are safe. We know that’s not true. Many times the danger lies in other medications, like benzodiazepines, that are prescribed with opioids.

This same law goes into great detail about how pain patients are to be screened before opioids for chronic pain are started, and how patients who are prescribed opioids are to be managed. Patients must be screened for past addiction, and for depression and anxiety disorders. The law outlines how patients are to be followed by their doctors. Washington’s lawmakers also mandate random urine drug screening of patients being prescribed opioids, and written patient agreements. The law gets in to specific details about what needs to be in the patient monitoring agreement.

Some doctors feel the government has overstepped its bounds and will interfere with physicians’ clinical judgments. Patients are already complaining that they have great difficulty finding doctors who will prescribe opioids to adequately treat their pain.

I support most legislation that helps physicians identify and treat opioid addiction, but I think Washington’s law has gone too far. Balanced, rational decisions are urgently needed. If we over-react out of fear, the pendulum will swing too far to the other side. Over-regulation could have unintended consequences including having patient in acute or pain or with cancer pain unable to get an adequate prescription for opioids.

1. 1. Missed Opportunity: A National Survey of Primary Care Physicians and Patients on Substance Abuse, Center on Addiction and Substance Abuse at Columbia University, April 2000. Also available online at http://www.casacolumbia.org  
2.  Under the Rug: Substance Abuse and the Mature Woman, Center on Addiction and Substance Abuse at Columbia University, 1998. Available online at http://www.casacolumbia.org
3.  http://www.doh.wa.gov/hsqa/Professions/PainManagement/

Smuggling Suboxone

I was intrigued by an article I saw on my internet homepage. It was titled: “When Children’s Scribbles Hide a Prison Drug”

http://www.nytimes.com/2011/05/27/us/27smuggle.html?_r=1&hpw

 This article describes unique ways Suboxone is being smuggled into jails. Law enforcement officials associated with both state and county jails from Maine and Massachusetts were interviewed. They say prisoners and their accomplices make Suboxone into a paste and smear it over the surfaces of papers sent to prisoners from their families. The article mentions the paste being spread over children’s coloring book pages, and under stamps. Suboxone films have been placed behind stamps or in envelope seams. Correctional officers now have to inspect material coming in the mail to prisoners much more closely.

 I had several thoughts. First, yet again, I’m struck by the creativity and cleverness of addicts. If only they could channel this energy in the right direction, amazingly good things could come to them, instead of the continued hardships brought by addiction.

 Then I felt sad that such actions described in the article would taint the reputation of a medication that has the potential to save lives, when used appropriately. Such illicit use of Suboxone gives ammunition to those who would prefer that office-based treatment with Suboxone didn’t exist.

 Then I wondered, how many of these prisoners have a legitimate prescription for Suboxone, but are denied their medication by prison officials? How many are legitimate patients of methadone clinics, also denied their medication while imprisoned, who know that Suboxone will alleviate some of the opioid withdrawal they are feeling? How many of these people are addicted to opioids, not in any kind of treatment, but who know Suboxone will treat their withdrawals?

At least one study supports the idea that many people use Suboxone illicitly not to get high, but to prevent withdrawal. Dr. Schuman-Olivier studied 78 opioid addicts entering treatment. Nearly half said they had used Suboxone illicitly prior to entering treatment. Of these people, 90% said they used to prevent withdrawal symptoms. These addicts also said they used Suboxone illicitly to treat pain and to ease depression.

Many law enforcement personnel and members of the legal community have strong biases against medication-assisted treatments. They don’t understand that addiction is a disease, and that methadone and buprenorphine are legitimate, evidence-based treatments. They have difficulty letting go of their idea that addiction is a choice that deserves blame, and have a punitive stance towards addicts. They have low opinions of addicts who are using drugs, but often have no better opinion of a recovering addict who has sought treatment and is doing well on replacement medications, like methadone or buprenorphine.

 But no matter what law enforcement personnel think they know, when they deny prescribed, life-saving medications, I believe they’re practicing medicine without a license.

The article mentions one woman who, with the aid of the Maine Civil Liberties Union, sued because her Suboxone treatment had not been continued while she was in jailed for a traffic violation. She settled out of court, but her lawyer made the excellent point that if inmates are denied their medications, they will try unlawful means to get it.

Other patients and their families have brought successful lawsuits against the jail facilities. In at least two cases, in the same Orange County, Florida jail, patient/prisoners were allowed to go through withdrawal for so long that they died. The estate of one person won a three million dollar judgment against the county. (1, 2)

I’m glad to see these lawsuits. I’ve heard appalling stories from many methadone patients, who were denied their medication while incarcerated. I’ve heard tales of jailers taunting these prisoners, when they became sick. There is no defense for such cruelty.

Orange County now works with local methadone clinics. If a prisoner is a current patient of a clinic, his clinic will send a week’s worth of medication in a locked box via courier. Nurses at the jail have the key to the box, and administer each day’s dose. The jail doctor consults with the medical director at the methadone clinic. Prisoners still have to pay out of pocket to get the medication, so the only cost to the jail is the time required for personnel to administer the medication. It’s certainly much cheaper than paying three million to the estate of a dead prisoner, not to mention much more humane.

I wish the county jails around the methadone clinic where I work would approach the problem of opioid addiction and treatment in a collaborative way. Sadly, only seven state prison systems offer medication-assisted treatment with methadone or buprenorphine.

Rikers Island, in New York City, gives us another example of how such a system could work. There, opioid-addicted prisoners charged with misdemeanors or low grade felonies can be enrolled in a program known as KEEP (Key Extended Entry Program). This program treats opioid addicts with methadone and counseling. Upon release from Rikers Island, these patients are referred to methadone treatment centers in the community. Seventy-six percent have followed through with their treatment, post-release. The results of this program show significant reduction in reincarceration and significant reduction in criminal activity. (3)

Drug courts trying to save money would be well-advised to look at the Rikers Island program. Studies have shown a cost savings of at least four dollars for every one dollar spent on methadone treatment. This money is saved because methadone patients require fewer days of hospitalization and other healthcare costs, and also because of reduction in criminal activity and incarceration costs. (3, 4)

I know from comments written to this blog that there are many more people abusing Suboxone than I previously imagined. For sure, some of the prisoners getting smuggled Suboxone are misusing it. But I don’t think the majority are using for anything other than prevention of withdrawal, since they are usually not offered any other effective treatment for this medical condition.

1. “Outrageous: the death of Susan Bennett raises serious questions about the competence and quality of the jail’s nursing staff” Orlando Sentinel, editorial, March 27, 1998.
2. Doris Bloodsworth, “Inmate begged for methadone” Orlando Sentinel July 12, 2001.
3. Par`rino, Mark, “Methadone Treatment in Jail,” American Jails, Vol: 14, 2000, issue 2, pp 9-12.
4. 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