I read the front page article in last week’s Alcoholism and Drug Abuse Weekly with mixed emotions. http://www.alcoholismdrugabuseweekly.com/
The state of Minnesota revoked the license of the only methadone treatment program in the city of Duluth and ordered it to shut down. This order was suspended until the outcome of an appeal by the owners on the clinic, Colonial Management Group.
I felt angry and chagrined. I support methadone treatment programs, both because they conduct one of the most evidence-based treatment interventions in all of medicine, and because that’s the type of setting where I work. I’ve seen the life changing benefits many patients get from methadone treatment. Closing this clinic would deprive opioid addicts of an effective treatment for their addiction in the city of Duluth, and existing patients would be essentially abandoned.
But bad clinics harm the reputations of good clinics. The list of charges against the clinic is appalling, and if true, couldn’t be ignored. I’d hope that instead of closing the clinic, some other option could be found. CSAT’s Nic Reuter, interviewed for the ADAW piece, said that in extreme cases, a team of professionals could be requested from CSAT, to come to this program and make changes, help turn things around.
I’m also suspicious. A Duluth newspaper had run a weeklong series of articles critical of for-profit methadone clinics just before the order to close was issued. Is this a bad clinic or the victim of a witch hunt? Were the inspectors pressured to find flaws, or were the flaws chronic and egregious?
I’ve worked for one non-profit program with several different clinic sites, and I’ve worked for four for-profit sites. If I graded overall quality of care, I’d rank the non-profit program fourth. Just because a program is non-profit doesn’t mean it’s well-run, and for-profit clinics often are extremely well-run. From my personal experience, the bias against for-profit programs isn’t justified.
Colonial owns fifty-eight clinics in seventeen states, according to the ADAW article. I’ve never worked at a Colonial clinic, but I do know they’ve had problems in other states.
At one Colonial program near me, I heard from several of their former patients that their clinic once ran short of methadone. According to these two sources, the clinic reduced everyone’s dose until they could procure more methadone. I would die of embarrassment if I worked for a clinic that did such a thing. I would much rather guest dose everyone at a nearby clinic so that the patients didn’t de-stabilize. Guest-dosing would likely cost both clinic and patients extra money, though.
The Colonial programs in my area also allow methadone patients to have prescriptions for benzodiazepines, because I’ve had a few patients transfer for that reason. In my medical opinion, this is prohibitively risky for most patients, though may be appropriate for a limited few.
I’m more suspicious than the average person because I’ve worked at a well-run clinic that was the victim of an apparent witch hunt. I believe the pair of inspectors from the state’s Division of Health Service Regulation arrived with an agenda…to uncover nefarious doings at the methadone clinic. Their routine would have been comedic, if the outcome hadn’t been so awful.
Prior to this encounter, I’ve had positive experiences with the state’s methadone clinic inspectors. They were educated and competent, and often able to suggest ways to do things better and more efficiently, based on what they’ve seen at other clinics. Before I encountered this pair, I viewed inspectors not as adversaries but as potential information resources.
These two were different. They caused one problem after another at the clinic they were inspecting. I wasn’t there, but heard second hand that they interrogated nurses and counselors in an aggressive and demeaning manner. I believe these accounts, because they did the same with me.
After several days spent inspecting and disrupting the clinic, they wanted to talk to me because I was the medical director at that time. First of all, they were an hour and a half late for our appointment, which did not endear me to them. When they finally appeared, their dress and demeanor didn’t inspire confidence that a fair evaluation was about to be done. One of them was openly hostile to methadone maintenance treatment and the other didn’t say anything…but she wore an outfit that could be fittingly accessorized by a lamppost and a public defender, if you get my drift.
The spokeswoman of the two was a nurse – she kept reminding me of that for some reason – who would ask questions along the lines of, “Have you stopped endangering patients yet?” A yes or no answer wasn’t possible. Plus, at first, part of my mind was distracted, marveling at the silent partner’s outfit. I was wondering if I could ever get away with wearing an ensemble like that to work. Probably not, since we couldn’t even wear open-toed shoes…plus, was I a little too long in the tooth to be able to pull it off?….Maybe if I had tattoos like her…
“Why do you let patients keep going up on their dose?” Her aggressive tone snapped me back to attention. “Wouldn’t you agree few people need more than 70mg?” I tried to educate her that best results were seen when patients were at blocking doses, and that 70mg wasn’t a blocking dose for many people. She stared at me over the top of her reading glasses for a long moment. Then she sighed deeply and slowly shook her head side to side as she wrote something on her papers.
Then she said I was providing substandard care by not doing EKGs on patients. This was in 2007, and ironically enough I’d just returned the week before from an ASAM conference where we talked in detail about whether EKGs should be done and under what circumstances. I told her there was no clear consensus yet, but that may become the standard of care. She argued, said no, I was wrong, that was the standard of care now.
She asked why patients with positive drug screens were allowed to remain in treatment. My eyelid started to twitch about them, because it was clear she knew nothing about methadone maintenance treatment, but held a strong bias against it. I told her many patients have positive drug screens, and we see best results by keeping them engaged in treatment. If they’re still using opioids, we actually need to increase their dose, as I described before. And she argued with me about that.
I asked if she’d ever inspected methadone clinic before ours. She said no, but that she was a seasoned state inspector. Hoping to educate her, I asked her if she was familiar with TIP 43, SAMHSA’s published guideline to methadone treatment of opioid addiction. She said no. I jumped up and ratted around in several counselors’ offices, finally finding a copy that wasn’t too dog eared. I gave it to her, hoping she would read it. If she’d read it before trying to inspect a methadone clinic, she’d have known how to do her job better.
The next day, I wrote a complaint letter to her supervisor at the state, describing her objectionable behavior and lack of knowledge. I heard nothing more until a few months later, when a disjointed and rambling report, authored by the nurse inspector, accused my clinic of numerous misdeeds. We were charged with two major level one violations and charged thousands of dollars in fines for substandard care.
Her report was so jumbled that I couldn’t tell specifically what the violations were, but they seemed to focus on a patient in methadone maintenance who had surgery and received post-operative pain pills. Her report said this could have caused a fatality and was substandard care. (So much for my hope that she would read TIP 43!). This patient had actually received great care. Release of information was passed both ways, to and from her methadone clinic. She didn’t relapse on her post-op prescriptions, and had no problems. But this inspector thought she ought not to have been allowed to take opioids post-operatively.
This report was released to local media, and an article based on her report landed on the front page of the city paper. The real facts – that this woman didn’t have the education to be able to know if a clinic was well-run or not – weren’t known to the writer at the paper. Our clinic, coincidently a non-profit, took the case to court. Possibly to avoid a public hearing, the state dropped the level one charges and the fines. The clinic was left with several misdemeanor violations, easily cleared up. Everyone seemed happy but I still object to the misplaced power this woman had. I had looked forward to a public hearing so that flaws of the present system could be exposed and fixed. This inspector had caused harm to our clinic’s reputation.
This year, five years later after that episode, I heard this same inspector, still employed by the state, gave a very negative report of another clinic. The regional director of that clinic described it as an unfair hatchet job, and I have no doubt that’s true. I don’t understand why the state allows such a person to represent them in the field.
So in summary, the Duluth Colonial program may be a bad clinic that should be overhauled and possibly managed by a special team if other treatment options can’t be located for the patients. Or it may have received unfair assessment by someone with a political axe to grind. Things are not always what they appear to be in the world of medication-assisted treatment.