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.

Advertisements

14 responses to this post.

  1. Posted by dbc910281927681 on October 11, 2012 at 5:25 pm

    One rotten apple spoils the lot. True of almost anything. Then laws get written that do more harm than good, or clinics shut down, causing more harm than they ever did while open. I hope this isn’t the future of Suboxone, because I’m sure there are shady Suboxone docs out there too. Of the ones I’ve encountered, most have had a surprisingly sincere interest in getting their patients clean. I mean, real sympathy, and empathy in many cases as I’ve found a lot of Suboxone doctors are recovering addicts themselves, or have had close family or friends who suffered through addiction.

    Reply

  2. Posted by Tamara on October 31, 2012 at 3:00 pm

    Wow, this is just disgusting behavior! I can’t believe this happened to your clinic and is still happening. I am a methadone patient here in Indiana, have been clean for a year now thanks to this treatment. I haven’t been clean since 13 years of age and I am now almost 30. I wish I was pointed to this treatment sooner, I could have started to re-build my life a long time ago. There’s something along the lines of that happening here, where a doctor with an axe to grind is writing resolutions to have all methadone clinics banned in the state of Indiana. If this happens and passes in the house of reps, thousands of people could be affected and lives lost. Just because people are uneducated and have a bias against something they don’t understand. Scares the crap out of me as a patient!

    Reply

  3. Posted by Chick Ensoup on November 1, 2012 at 9:14 pm

    “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 am not sure who your sources were, but they were incorrect. Colonial did run short of methadone but no dosage was reduced.

    Reply

    • Duly noted, thank you.

      Reply

    • Posted by MICHAEL P on February 23, 2017 at 12:43 pm

      Cut the dose ppl would riot at my clinic and go out and use heroin you cannot cut heir dose that is illegal isnt it ? You have a stable patient and oh ya we cut your dose by half they will not even drop you over 5 mg per week at mine without signing a paper saying it is against what they recommend so cutting it by say 60 in one day WOW ya 2 words F*****g Riot.

      Reply

      • Posted by MICHAEL P on February 23, 2017 at 12:45 pm

        Oh ya I am at one of the biggest clinics in the Usa in Indiana I live at the Indiana Ohio Kentucky border which there is over 6 clinics near me. The one I am at was once the biggest not sure think that has changed but they also had the most patients i know at one time there was over 1500 I had to wait 1 hour in line before sometimes 1 hr 45 minutes it has changed now I only wait 10 minutes but ppl start lining up outside before they open its crazy its packed

  4. I have to wonder why they ran short of medication, was it an error on the part of a shipping clerk, were supplies of medication low or did they just forget to order more medication?? So glad that the doses of Patients were not lowered to compensate!!
    It is negligent that the state would keep an employee that refused to educate themselves about a treatment modality, these are people who are being paid by taxpayers. It is obvious that she has not made herself familiar with TIP 43 , should these State Employees have to be educated?? Interesting that the State dropped the case . I would like to see more positive articles on MMT programs and Patients, but most Patients are too busy with work, school/education, Children/Grandchildren,Voluteering ect. to write the new media about their busy lives. So many times the public is more interested in those who do not follow society’s rules !! Who wants to hear about those who pay thier bills, go to work daily, take care of their Children , volunteer at the local animal shelter and mow their own yard. Pretty boring stuff there , huh?? Just Keep ON!! Keep up with your state Regs. know who your legislators are, contact then when you need too!!
    Thankyou Dr. Burson for providing this space!!

    Reply

    • Posted by Todd on December 27, 2012 at 7:16 pm

      Methadone had changed me from a heroin addict and a thief, to a productive member of society. I am proud to say that after some initial positive UA’s (which increasing my dose solved), I have successfully not used narcotics for over 5 years and am looking forward to tapering off with the use of Suboxone shortly. I have also worked a job and volunteered throughout my recovery and am currently approaching a college degree. Methadone is not about just switching drugs. It’s about a second chance to live and has saved my life.
      Obviously these particular state’s methadone clinic inspectors have a bias and are unwilling to effectively do her job if she wont even read TIP 43 and not just take it seriously, but use it as a guideline as a basis of how to perform their job, obviously should not be in the position of power that they are in. I agree with you Tamara that bias people with axes to grind trying to create resolutions to change laws as well as the media giving MMT a negative spin scares the hell out of me too! This is life or death. I think b. cohen-feinsilver gives the best advice: know who your legislators are, contact then when you need too!!

      Reply

  5. Posted by Carolyn P on July 21, 2013 at 1:22 pm

    I have been off methadone since May 2012, and I was a patient at a local CMG clinic for over a year (and a previous NON PROFIT clinic that was VERY different for a year before that), and TRUST me, it was very easy to increase dosage- I know people who are on 300 mg of methadone daily, and take it from a true recovered addict, people go up because they want to get high (good luck). Then try to decrease your dose!!! Oh no, the rules change all the time, one day they’ll let you go down no problem and the next time they tell you that you have to be at the dose a certain length of time. When you look at the PURPOSE of a methadone clinic, it makes no sense to allow FOR PROFITS. Those businesses are operating with their eye on the bottom line, not getting people better.

    I also needed the methadone to overcome the craving part of the addiction– the mental craving. But let’s look at how an addict REALLY reforms him/herself: First, addiction is a cycle, you have to get out of the cycle. Sure, counseling is great, but I have yet to meet any drug counselor that knows whether a patient wants to increase dose because of a real need, and ALL addicts learn how to get what they want. Going to a dispensary every day, having to scrape money to pay for your fix, even going so far as pawning your kid’s Playstation because you know you cannot function without your medicine. The dependence is just as prevalent with methadone as it is heroin or morphine. The difference is my dealer would let me get pills on a promise to pay later, the clinics don’t. So they get you in, get you on a DIFFERENT drug, take your money, even if it’s the last dollar you have. I have seen a couple go homeless for a year, having 4 kids, and pushing them around town in a stroller because they don’t have the money to fix their flat tire on their van—but they sure got their methadone. How is this different from your local for profit heroin dealer? Uh, it’s only different because it’s legal, and it only works for people who truly want to recover. Besides that, all it does is funnel money that USED to go to the black market into the NY Stock Exchange. So the cycle only changes because you don’t have to keep your addiction secret–the other behaviors do not change.

    Reply

    • Of course I don’t agree with much you’ve said, but I think the key phrase you used is, “it only works for people who truly want to recover.” Opioid addicts who enter methadone maintenance treatment and who want to recover do very well. Their behavior does change, because they take advantage of the individual and group counseling. I have seen spectacular life changes in these patients. They get jobs, become better parents, and are able to live the way they want to live, without worrying about where they are gonna get the next one. It’s why I do what I do. I never saw that kind of improvement in people’s lives when I worked in primary care.

      Oh and by the way – many healthcare agencies are for-profit corporations. Yes, their eye is on the bottom line. Healthcare is a business in this country, and opioid addiction treatment is a business too. I may have ideas about how things could be better with healthcare, but it is what it is. Maybe Obamacare will help, maybe it won’t.

      We have 40 years of studies that tell us methadone treatment decreases drug overdose deaths and suicide, improves overall physical health, dramatically reduces crime, increases employment, and decreases the risk of HIV.
      Get serious…opioid addicts with a $100 a day heroin habit are much more likely to pawn their kid’s playstation than opioid addicts in treatment who pay $11 per day for methadone treatment!

      Reply

  6. THESE CLINICS WOULD BE OK IF THE STAFF WOULD KNOW WHAT THEY ARE DOING. IT IS SUPPOSE TO BE A DETOX AND ITS NOT THEY KEEP TAKING YOU UP ON YOUR DOSE ITS NOTHING BUT A MONEY PIT MY BROTHER WAS ON IT FOR TWENTY YEARS UNTIL HE DIED 2 YEARS AGO REALLY I THINK THEY SHOULD CLOSE ALL OF THEM BECAUSE YOU CAN ALWAYS GET OFF OF DRUGS YOU JUST HAVE TO SAY NOOOOOOO AND BE STRONG. IT S HARDER TO DO GOOD AND EASY TO DO BAD!!!!!!!! BUT IT CAN BE DONE I AM LIVING PROOF AND SO ARE ALOT OF OTHER PEOPLE!!!!!!!!!!!

    Reply

    • I decided to post this as an example of the opposition many OTPs face.
      “Nothing but a money pit…” as if medical care is free for all other diseases in this country???
      “You just have to say noooo…” Oh if it were only that easy. If a person can stop by saying no, they don’t need treatment. Treatment is indicated for those people who can’t just say no. And the comment about harder to do good than bad – clearly she considers addiction more of a moral issue. It’s really not about being good or bad. *SIGH*
      I see so many patients who became addicted not knowing how hazardous opioids were. They weren’t warned because even their doctors didn’t realize how common opioid addiction is.
      I am sorry she lost her brother. I know the pain of losing a loved one.

      Reply

      • Posted by John on March 17, 2015 at 12:42 am

        Jana,

        I’ve been having some rough times lately. After a pretty serious heroin problem, I’ve been in a suboxone program for nearly four years now with pretty great success. But my doctor is insisting (more or less) that I taper off the suboxone.
        Anyway, I’m very hesitant about tapering off. It’s really not something I want to do. But I feel like I have so little control over my program, and it’s distressing. I’m considering switching to methadone. But anyway, I just wanted to say that I really admired and appreciated your editorial. I think maintenance programs have been of great benefit to the opioid dependent, but we as a society cannot see past the supposed moral ambiguities of methadone. We insist that addiction is a disease, so we can excuse the harmful actions of our loved ones, but we refuse to accept that the disease might require a medication.

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s

%d bloggers like this: