Hazelden Advances into the Twenty-First Century

In last week’s edition of Alcohol and Drug Abuse Weekly, I read that Hazelden’s addiction treatment center now plans to add medications to the treatment they provide for opioid addicts. Presently an abstinence-based, 12-step recovery center, Hazelden plans to have three treatment tracks available for opioid addicts: one offering buprenorphine (Suboxone), one offering naltrexone, and the traditional non-medication program that is now provided.

Better late than never.

Naltrexone, as an opioid block, isn’t controversial, since it is an opioid antagonist and therefore gives no opioid sensation. However, it will block any other opioid from acting on the brain. I call naltrexone the “anti-opioid.” It’s useful as an insurance policy for opioid addicts because if they relapse while on it, they won’t feel any opioid effect. For patients struggling with opioid withdrawal, this medication will not help, and in fact may make their withdrawal worse. Frankly, I thought Hazelden was already using naltrexone.

Their chief medical officer, Dr. Marvin Seppala, said Hazelden decided to use medications to treat opioid addiction in response to the public health crisis of opioid overdose deaths. Now more common than fatalities in car crashes, Hazelden feels opioid overdose deaths, “Demand up-to-date, evidence-based treatment protocols that offer the brightest promise of recovery.”

He says using the buprenorphine will help stabilize patients so that they can better engage in counseling and 12-step recovery. He says the patients will be watched and monitored closely, and will be in outpatient treatment settings while they are on buprenorphine. He also says, “Ultimately, we’ll have people come off these medications.”

I have mixed feelings when I learned all of this.

Predominately, I feel happy and relieved. Finally, a respected big-name, 12-step abstinence based treatment center is going to use medication that’s been proven to prevent overdose deaths. Hazelden is taking a huge step by moving away even a little bit their anti-medication dogma. Hopefully their action will influence the rest of the treatment field that has so far rejected medication-assisted treatment for opioid addicts.

True, Hazelden’s press statement said they didn’t look at buprenorphine as a long-term solution, and set complete abstinence as the goal for opioid addicts, but it is movement movement in the right direction. They should be praised.

On the other hand…the cynic in me raised an eyebrow as I read the article. Really? Up-to-date??  I think not. Suboxone, approved in 2002, was available as of 2003. That’s nearly ten years ago. How many addicts have died because of the addiction treatment establishment’s anti-medication biases, which prevented them from endorsing buprenorphine as a viable option in a timely fashion?

I have buprenorphine (Suboxone) patients who say they wouldn’t be alive if not for this medication. Many of these folks cycled in and out of 28-day treatment programs, good ones, but that path didn’t work for them. Most weren’t told about buprenorphine as a treatment option by these addiction treatment programs. Most learned about buprenorphine from other addicts. That’s sad, and unprofessional.

Change is hard. Once an abstinence-only treatment provider myself, I know how hard it is to take a step back, and say wait a minute…here’s some real proof that this new method may be better, though it goes against my present mindset. But if doctors and other professionals treating addiction want to be taken seriously, we have to constantly re-evaluate what we are doing, to see if we are up-to-date with best practices. We must keep an open mind and a willingness to change. That’s important in all of medicine, but especially true for addiction medicine, where things change rapidly.

After all, isn’t an open mind and a willingness to change what we ask of our patients?

Kudos to Hazelden for taking a step forward.

Closing Down a Methadone Clinic

 

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.

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.

Staff Meetings

 At both of the opioid treatment programs where I work, we do case staffing at the end of our day. Case staffing means all of the staff – program manager, counselors, doctor, nurses, and front office people – all meet to talk about how our new and established patients are doing. This helps us know what’s going on with the patients. Good clinics have excellent communication between staff members, and meetings make an easy way to communicate.

I want to explain this because some commenters to this blog say their counselor has too much power over decisions like their dose and their take home levels. Good clinics don’t allow this. Good clinics get input from all staff members when making difficult decisions, so that no one person, even the doctor, can allow personal biases interfere with clinical decisions.

The physician or physician extender should, however, be the only ones determining dose. Sometimes we do get information from the patient’s counselor, and also from the nurses, but ultimately it’s a medical decision made on medical grounds, preferably with a face-to-face discussion with the patient.

Take home levels are a little different. The relatively strict state and federal take-home regulations don’t allow too much flexibility. For example, if a patient has two positives urine drug screens within 90 days, we must reduce the take home level to be in compliance with regulations. If we don’t follow these regulations, state and federal inspectors could take measures against the clinic.

However, we have leeway in other areas, like returning take home levels to the patient. This is a common case staffing issue. During case staffing, the counselor may say something like, “Patient X lost her levels due to 2 positive urine drug screening, but she’s had a negative drug screen and has made progress in counseling. I think she’s ready to return to her previous take home level.” Unless one of the team has an objection, she’s returned to levels. If one of the team has seen something worrisome regarding the patient, we talk about that. We do realize that losing take home doses is an inconvenience and often expensive, given the price of gasoline. It isn’t something we take lightly. On the other hand, we want to make sure patients are safe.

At case staffing we also discuss newly admitted patients. The counselor might see the patient needs help with an abusive spouse, for example, or be referred for help seeking employment. I might see a need for referral to a medical specialist. All of these sorts of issues with go into the patient’s treatment plan.

For example, last week I admitted a patient who had a history of depression that pre-dated her addiction history. Her depression had been severe, though it happened in her late teen years. She was depressed at admission, as so many patients are, but she thought it was from being in withdrawal and physically miserable so much of the time. Our plan for this lady was to observe her for a few weeks, then have her see me again, after she was on a stable buprenorphine (generic for Subutex) dose. I’ll assess her mood again, and refer for treatment of her depression if needed.

When all of the patient’s treatment team members are informed of what’s going on, it leads to more efficient and focused care for the patient.

Second, we share our ideas and impressions. For example, at case staffing a few weeks ago I discussed a patient who I thought was relatively uncomplicated. During case staffing, the counselor mentioned he told her he was a heavy drinker. I’d asked him about alcohol too, but got a different history of consumption compared to what he told her. Because of that, we decided it would be safer to check breathalyzers daily for the first month, and randomly after that if they were all negative. Since alcohol can be fatal when mixed with methadone, this will help us dose him safely.

Sometimes we brainstorm about how to solve a problem that’s come up with a patient. For example, we got frequent reports from friends and relatives about a patient. They would call the clinic, saying she was using large amounts of Xanax, but she never looked impaired when she came for her dose. All of her urine drug tests were negative, and we knew she wasn’t getting any prescriptions for Xanax. So what was going on? Was she somehow falsifying an observed urine drug screen? Or were people trying to get her “in trouble” with the clinic, as she claimed?

The nurse, very experienced, ordered “hats.” These are plastic containers hospitals use to measure the amount of urine the patient is making. It looks like a hat with a wide brim, only this thing goes upside down, under the toilet seat so that it catches the urine.  This way, a female patient can be asked to sit down and provide a hands- free urine sample. This is easier for women anyway, since we have a harder time getting urine into a little collection bottle. And the hands-free part eliminates some of the methods we’ve seen for tampering with urine samples. The first hands-free sample we got from this lady contained benzos, so now we know we need to address this problem.

We also use case staffing to celebrate victories. Last week one of the counselors opened case staffing by saying, “I want everyone to know that [name withheld] had her first ever negative urine drug screen for marijuana.” Everyone cheered. This lady has been in and out of treatment for years. At one time I thought she was going to die from combining methadone and benzodiazepines, and her counselor worked very hard with her. The patient worked even harder, going to group meetings and individual counseling sessions, and avoiding people she used to use drugs with. She finally stopped using benzos but still smoked marijuana. She had a willing spirit, and continued to work with her counselor. Now, many months later, she’d stopped all illicit drugs and is taking only methadone, as prescribed. She just went to level 2, a victory we all cheered. Of course, all of us at the treatment center like to think we were at least a small part of her success, but she did most of the hard work. Her life continues to improve, and we took a moment to celebrate her success. She didn’t get well over night. Few patients do. Addiction is a chronic disease, subject to relapse and remission.

Case staffing helps point out our blind spots and prejudices we have with patients. No one is perfect. I have my favorites, and my no-so-favorites. It’s part of being human. I may over-react or under-react to a patient. It’s good to have staff balance each other. The decisions that affect our patients should be made in accordance with state and federal regulations, but in situations where we are free to use our judgment, it’s better if it’s a group decision.

We talk about hard decisions at case staffing. For example, a few weeks ago we talked about a patient who stopped injecting heroin when he got to a moderate dose of methadone. But he wasn’t doing well with cocaine, and still snorted it on a regular basis. He’d discussed his cocaine use with his counselor numerous times. She had used cognitive behavioral techniques and motivational enhancement counseling, to no avail. He met with me a few times too. He said he really liked cocaine, he didn’t think he could stop, and in fact he didn’t want to stop. He had come to treatment because he wanted to stop his intravenous use of heroin. Since he snorted the cocaine instead of injecting it, he didn’t see it as dangerous. He had a fatalistic view when I informed him of possible medical complications from cocaine us. “You gotta die from something, doc.”

So here’s our dilemma: do we keep him in treatment? I said yes, because we were helping him, to some degree. He isn’t shooting heroin and that’s a big improvement. One counselor and a nurse said we should refer him to an inpatient program because he was still using drugs, and was still putting his life in danger. What if he died while on our program? Would be liable somehow for his death? Would we be responsible, either legally or ethically?

I countered with data that patients who leave methadone treatment die at a rate eight times greater than those who stay in treatment. Therefore, a decision to take him off methadone is monumental.  Of course we would want to refer him to a higher level of care, meaning an inpatient admission, but in reality most of our patients don’t have insurance or money to pay for this, and refuse to go anyway.

These are tough cases with no easy answers. What I see as harm reduction, the next person may see an enabling. I used to think I had all the answers; now I see more and more questions.

Great Book About Opioid Addiction!!!

I orginally started this blog to promote the book I wrote about pain pill addiction. As it’s turned out, the blog has been much more popular than the book (it isn’t exactly flying off the shelves), so I’d like to remind blog readers – again – that if you like the blog, you’ll love my book.

You can order it from Barnes & Noble, or Amazon. But I’m selling it for a much-discounted rate of $13.95 on EBay. That’s with shipping included.

http://shop.ebay.com/i.html_from=R40&_trksid=p5197.m570.l1313&_nkw=pain+pill+addiction&_sacat=See-All-Categories

Pain Pill Addiction: Prescription for Hope

Finally, here’s the cover of my book about pain pill addiction and its treatment. It’s available at http://prescriptionforhope.com or you can order it from Amazon, and soon from Barnes and Noble.

My book contains much of what I’ve been blogging about. I wrote the book because there are so few sources of reliable information about the treatment of opioid addiction (pain pills). It seems  that abstinence-based programs don’t like to talk about medication-assisted programs, and some methadone clinics don’t let their patients know about other options. Methadone and buprenorphine can be life-saving when used appropriately, but they have some drawbacks, as well.

There’s not one single right answer for all opioid addicts. Some treatments work for some patients, but no treatment works for all patients. In my book, I present the data supporting treatment methods, so opioid addicts and their families can chose the best course.

If you like this blog, you’ll like my book. I also have a chapter in the book about the unjust stigma patients face when they are treated with medication-assisted methods. It takes a strong person to stay on a treatment that helps them, despite criticism from friends, family, law enforcement, and even unenlightened medical professionals.

Law Enforcement Behaving Badly

Many law enforcement personnel and members of the legal community resist medication-assisted treatments. They seem to have difficulty letting go of their idea that addiction is a choice that deserves blame, and have a punitive stance towards addicts. I find it difficult to work with these professionals. 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. Law enforcement personnel have ways of letting methadone patients know they are regarded as if they’re still using drugs.

            When I worked at a methadone clinic in the mountains of North Carolina, we had a Tennessee resident, a pregnant woman, who committed a crime before she sought treatment at our methadone clinic. By the time she was sentenced to three months of incarceration, she was seven months pregnant. She asked to begin her sentence after delivering her child and her request was denied by the judge. He said he would cure her addiction by placing her in jail and then, at least, the baby wouldn’t be born addicted to methadone. He had been informed she was in treatment at a methadone clinic in North Carolina.

The patient contacted her counselor at the methadone clinic, in a panic, because she knew she could miscarry if denied methadone.  Opioid withdrawal could even kill her fetus. Her counselor called me and related all of the details.

I was surprised that a judge would make a medical decision like that, and if he did, it was only because he didn’t have information about methadone. I called the judge’s office, but couldn’t get through to him. I explained everything to his clerk, and believed the patient would either be given methadone in jail or have her sentence postponed.

The next day the patient called, and said she was still going to start her sentence in two days, and that the judge hadn’t changed his mind. I called the judge again, and was told the judge wasn’t going to come to the phone to speak with me, the clerk had relayed the message, the mother was going to jail and no, she would not be given methadone.

Now irritated and worried, I composed a letter, detailing the possible medical complications that could occur, as a result of the judge’s uninformed and ill-advised decision, and told him this was a medical decision that should be made by doctors. I described the preterm labor that could occur, if the mother was allowed to go into withdrawal. The fetus may not be able to survive if born at seven months’ gestation. I ended with a plea that no matter what he thought of the mother, the baby at least should be given the best chance for survival. I faxed a copy to the judge and a copy to the patient’s lawyer. Later, I heard she was allowed to deliver a healthy baby boy, prior to beginning her three month sentence.

Recently, I was asked to speak at an addictions conference, in the heart of the Blue Ridge Mountains, about methadone and its use in the treatment of opioid addiction. The speaker who gave a presentation after me was a lawyer with the local drug court. He explained how drug court got addicts, who committed crimes related to drug use, to participate in treatment, rather than just sending them to jail.

During the question and answer session, he was asked if patients on methadone could participate in the drug court program. He said no. When asked why this was, he said that to participate, the addicts must be completely drug free. Another member of the audience asked why this was the case, if methadone was a legitimate treatment and it had been started by a physician.

            The lawyer did not give a clear answer, but turned to the program director of a local outpatient treatment center, sitting in the audience.  The drug court contracts with this outpatient treatment center, to provide the counseling needed for the addicts participating in drug court. This program director said that addicts on methadone couldn’t come to the counseling his center provided because they “would give their methadone to other patients and nod off in treatment sessions.”      

            This was a clear example of the biases methadone patients face. I had just completed a lecture about methadone and had explained how opioid treatment center patients don’t receive take home doses for at least the first three months, and how patients on the right dose are not sedated, unless they use nerve pills or other sedatives. In the above case, both the court and the treatment program were opposed to methadone, and they didn’t have a clear policy on buprenorphine.

            That said, at present, the majority of drug courts don’t allow participants to be on methadone, though methadone has been shown to be very cost effective as well as beneficial to opioid addicts.

            At Rikers Island, in New York City, 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.

            Drug courts would be well-advised to look at the Rikers Island program, for an example of the effectiveness of methadone maintenance. They should also consider the amount of money it can save the community. 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. (1)

            Many jails will not dispense methadone to prisoners who are patients in at a methadone clinic, even if they are doing well and on a stable dose. Many times, these patients are allowed to go through a terrible withdrawal. Patients tell me they have been taunted for being ill from withdrawal from methadone, and refused access to medical care. This refusal to treat an illness with an accepted and effective medication has been costly to at least one county in Florida.

            In 1997, an Orange county jail inmate died after being denied her usual dose of methadone. She spent twelve days in withdrawal, before she was found dead in her cell. The family sued the county and won a three million dollar settlement. (2) Then in 2000, a second person died in the very same Orange county jail, under nearly identical circumstances. (3) She had been a patient at a methadone clinic for about five months, before entering the jail. She was denied her medication, and was found unconscious three days later, from an apparent seizure. She was then taken to a hospital, and her family removed her from life support five days later.

            In 2001, Orange County decided to offer methadone to patients who were already established at a methadone clinic, and continue their dosing. They’ve worked out arrangements with a local methadone clinic to provide the necessary methadone. Opioid addicts who are not established in any kind of treatment are treated with a standard opioid withdrawal protocol. Soon, Orange County may begin to use buprenorphine in this jail setting.                                                                                                                                                              More jail facilities would be wise to heed the experience of Orange County.

            In Cook County, Illinois, a man serving a ten day sentence for a traffic violation died of methadone withdrawal on his sixth day of imprisonment. He was an established patient of a methadone clinic, but the jail refused to provide his methadone medication. He made repeated requests for medical attention, but was denied care, despite his obvious physical suffering, witnessed by at least three jail employees. (4) He died of a cerebral aneurysm, as a result of opioid withdrawal. His wife and estate sued the county, for failing to provide timely medical treatment, charging them with deliberate indifference to the suffering of the prisoner. 

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.

            On a positive note, more jails and prisons across the U.S. are beginning to offer access to medication assisted therapies, with both methadone and buprenorphine. Colorado has several counties that coordinate care with local treatment centers. A clinic within Albuquerque’s city detention center offers treatment with methadone. Rhode Island’s department of corrections contracts with a local treatment center, to treat opioid addiction. The jail in Seattle-King County, Washington, plans to offer both methadone and buprenorphine soon.

            Will this country ever become civilized enough to provide appropriate medical care to patients on replacement medications while they are in jail? I hope so. Sadly, it appears that litigation is the only way to get the attention of some jail facilities.

1. 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
2. “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.
3. Doris Bloodsworth, “Inmate begged for methadone” Orlando Sentinel July 12, 2001.
4. Davis vs Carter, #05-1695 US Court of Appeals, Seventh Circuit http://openjurist.org/452/f3d/686/davis-v-carter

Me, Behaving Badly, Sometimes

 

I’m really good at pointing out the bad behaviors of others. It’s like shooting fish in a barrel. It’s not so easy to see where I fall short of the ideal, because I have the usual human blind spots.

 

At times, doctors, nurses, counselors, and administrators who work in opioid treatment programs underestimate the emotional burden that recovering addicts on replacement medications feel from depending on a clinic or physician to prescribe with methadone or buprenorphine.

Some clinics may use the methadone dose as a way of punishing patients for bad behavior, an unethical policy which causes an adversarial relationship between the clinic personnel and the patient. Patients fear the medication they need to function may be changed at the clinic’s caprice.

 Sadly, clinic personnel occasionally behave badly towards patients. Addiction treatment professionals have let personal feelings toward some addicts color their decisions. They can play favorites, or even worse, punish a patient because of their own feelings toward an addict. Seeing this, it’s no wonder some patients may, at times, feel their dose or take home schedule can be changed at the whim of the clinic’s counselor, doctor, or program manager. Clinics must watch closely for such unprofessional behavior among all staff.

One system of checks and balances for all people who work in this field can come at case staffing meetings. This is when all parties who have a role in a recovering addict’s treatment come together to discuss how the patient is doing. At these meetings, members of the treatment team need to watch each other for indications of bad feelings towards individual patients.

For example: Maybe one of the patients reminds me of Little Denny who stole my lunch money in fifth grade (if you’re reading this, Denny, mail me my fifty cents!), so I have some notion that this patient who reminds me of Denny can’t be trusted with take home doses. Other people on the treatment team would hopefully challenge me to consider why I think the patient is such a risk, since my feeling isn’t based on observable facts. More often, workers at the treatment centers develop “wellness biases” for certain patients. Even if the patient is not doing well, the counselor (or doctor) makes excuses why everything seems to be fine, because they so fervently want that patient to be doing well.

The counselors, doctors, and nurses who work at methadone clinics are only human, and dealing with addiction can be draining. The disease of addiction can create behavior that could make Jesus gnash His teeth, but treatment personnel must learn not to personalize the behavior of addicts, and deliver professional care, no matter what.

Methadone Clinics Behaving Badly

Not all methadone clinics are equal. We know what qualities are associated with the best outcomes, and hopefully every clinic is trying to improve.

First, many clinics should be called “opioid treatment centers,” because they offer more than methadone; they also prescribe and dispense buprenorphine. In the future, buprenorphine will likely be the first line treatment for opioid addiction replacement medication, with methadone saved for people who don’t do well on buprenorphine, usually because it’s not strong enough. In the very near future, buprenorphine may replace methadone as the treatment of choice for opioid-addicted pregnant patients.

Besides the ability to offer buprenorphine, the best clinics have well-trained staff with low turnover. This seems obvious. It’s difficult for a patient to participate in counseling with enthusiasm when they’ve had three different counselors within four months. Sadly, this is an area of counseling that has difficulty retaining counselors.

 And while we always need to be open to learn from our patients, a counselor should already know the basics about opioid addiction and its treatment with replacement medications before he sees the first patient. I’ve heard the occasional counselor voice doubts about the benefits of replacement medications. If the counselor can’t wholeheartedly support their patients, they need to go back and read the basic research, or move on to a different field. An ambivalent and uninformed counselor can taint the treatment milieu at an otherwise good clinic.

Doctors prescribing the methadone or buprenorphine should be willing to give adequate doses. Clinics who were stingy with dosing had worse patient outcomes in many studies. In the past, clinics were reluctant to dose above 60 or 70mg, but we know now that patients do better at adequate doses, and there’s a wide variation between patients as to what’s an adequate dose. Most patients stabilize on between 80 to 120mg, but some need much more and some need much less. Cookie cutter dosing isn’t best practice.

Counselors shouldn’t have overwhelming caseloads. The regulations say each counselor should have no more than 50 patients, but even that’s too many with the growing documentation requirements.

Clinics shouldn’t let a few patients, not doing well and causing chaos in the community, to remain in the clinic, dosing daily with methadone or buprenorphine. The reputation of opioid treatment centers is too important and too fragile. In many communities, laws have been passed to limit the number and type of drug addiction treatment centers, because of the community’s perception that the patients will create havoc locally. In reality, very few patients behave like this, but the ones that do create the illusion that all patients will drive while impaired, or shoplift at local stores. Some patients are too sick or too unwilling to do well at an opioid treatment center. These centers owe it to their other patients and their community to refer patients doing poorly to other options.

Now for the number one most important factor that determines how well a patient will do while in treatment at an opioid treatment center…a warm and empathetic relationship with treatment center staff. This means all staff, not just their counselor. It includes the nurses and doctors and clerical staff.

It appears that behavioral change with addiction is more likely to occur when the people trying to help are caring and compassionate.

What an epiphany of the obvious.

Addiction Treatment Centers Behaving Badly

A dear friend of mine, who happens to be the best addictions counselor I know, was turned down for a job at a nearby inpatient drug addiction treatment center. They said it was because of his criminal background. He has non-violent felony offenses directly related to his active addiction.

 OK. You’re thinking, “I could see that. He might steal or something.”

 But the felony occurred more than a decade ago. He has had over a decade of stable recovery from the disease of addiction. It astounds me that a drug addiction treatment center – theoretically in business because they believe change is possible for addicts – refuses to hire such a person, who has been able to change his whole life since entering recovery. Is he not more likely to be able to teach addicts how to change and recover than someone who is educated about counseling but has no personal experience?

 I am in favor of having educational standards for addictions counseling. Treatment centers shouldn’t be able to hire people off the street to be counselors if they’ve had no training, even if they are recovering addicts. But my friend isn’t only in recovery; he has a B.S. in Psychology and a Master’s degree in both Community Counseling and Addictions Counseling. I suspect he’s one of the more qualified applicants they’ll have for the job.

 My friend, though disappointed, isn’t bitter. He knows there are other treatment centers, and he will find the job he’s meant to have. It’s not his loss. It’s the treatment center’s loss. They lose out on his amazing ability to help people with addiction.

 I’ve referred patients to this inpatient program. Should I continue to send patients to that center? I don’t want them to be tainted by the attitude that they won’t be able to overcome what’s happened in the past.

  I know decisions about hiring ex-cons and recovering addicts are made high up in this organization, and not by the people actually working in the trenches. Still, I’d rather patients get help at treatment centers who practice what they are supposedly teaching.