Following is an interview with a successfully recovering opioid addict. He received treatment at methadone clinics off and on for years, and finally achieved medication-free recovery after going to an inpatient treatment program for 42 days. Later, he began to work in the field of addiction treatment as a methadone counselor. He was promoted multiple times over the years to his present position as director of the narcotic treatment program at his clinic. This is his perspective about his own experience and what he’s seen with methadone treatment.
JB: Can you tell me your title at the opioid treatment clinic where you work?
KS: Director of Narcotic Treatment, which is our opioid treatment program. [He supervises counselors working at multiple clinic sites, with a total census of around thirty-four hundred methadone patients]
JB: Can you please tell me about your own opioid addiction, and how you got into recovery, including what kind of substances you may have used, what kind of treatments, and your experiences with them?
KS: I started out using pain killers, mostly Percodan tablets, back in the late 70’s, which lead me to using heroin. Heroin wasn’t easy to get [where I lived], so I started using Dilaudids [a name brand of the drug oxymorphone]. I started using Dilaudid on a regular basis in the county I lived in. That was the primary drug I used for quite a few years.
[My] first experience with methadone treatment started in 1978, with a brief episode of treatment, a matter of a month or so, with no success. Pretty much during the 1980’s, I was on and off methadone programs with little or no success, because I refused to participate in group or individual sessions. At the time, there was very limited counseling going on [at methadone clinics]. If there was a problem, you saw your counselor, and that didn’t happen a whole lot. Patients were simply trying to get more methadone. At that point, the methadone dosages were very low. I think the average dose back then was somewhere between forty and fifty milligrams. And we [patients on methadone] didn’t know that. We didn’t know that. We just found out through….
JB: You didn’t know what dose you were taking?
KS: Oh, no. We didn’t know what dose we were taking, for a number of years. As a matter of fact, that didn’t change until right before 2001.
JB: Could the patient find out if they wanted to? [the dose they were taking]
KS: We were blind dosed then. That didn’t change until just before 2001.
JB: Was that unusual for methadone clinics to do?
KS: To my knowledge, I think we [the clinic where he now works, and previously was a patient] were one of the last ones to keep doing that. It was just something we had done over the years and never changed it. [The patients] didn’t know what their dose was.
Through the 1980’s, I was on and off methadone programs, sometimes for a few years at a time, and sometimes had some success. The biggest benefit I had from taking methadone and being on the program was that I was able to work. I held a job the entire time, and I wasn’t doing anything criminal. It served the purpose it was supposed to serve there, because I had to work, and I was able to function fairly normally. But I never moved into actual recovery, and still used some opiates from time to time. So that was pretty much the 80’s. Two good things happened in the 80’s. In 1981 my son was born, and in 1989, I got clean.
JB: Big things.
KS: Two monumental things in my life. So, I went through that period of time I had talked about, when I started using opiates, in about 1974. Then I started getting on the methadone programs, on and off, [starting] from ’78, but I continued to use. I was using Dilaudids on a daily basis for a number of years. When I got on the methadone program, I would curtail that, but always wanted to go back to Dilaudid. That [Dilaudid] became my drug of choice.
I was on the methadone program in 1989, and having some problems with alcohol. Prior to getting on the program, I was told, “We’re not going to allow you on the program, unless you go on Antabuse.” So I did that and I was successful at stopping drinking, and had some success with methadone. I decided I wanted off the methadone, started detoxing off, and had a series of positive drug screens for a variety of opiates: morphine, Dilaudid, and several different things I had access to. The methadone center said, “We’re going to make a recommendation that you enter residential treatment.” And I said, “Sounds great to me, I’ll do that in a couple months.” And they said, “No. We’re going to make a recommendation you do that… pretty quickly.”
And that’s what happened. I said, “I don’t think I can do this. I’ve got some things to do.” And I remember it like it was yesterday. The counselor got up and walked out of the room and he left me sitting there by myself. Then he walked back in, said, “We’ve got you a bed.” And that’s what lead me to [inpatient treatment].
So I went to forty-two days of residential treatment, and actually entered that program ready to quit using and get into recovery. And from that point on, recovery has been the most important thing in my life….family, of course…but I’ve pursued recovery since May 3, 1989. I followed all the suggestions. [I’m] still really involved with 12- step meetings, and still really involved with some of the same things I did when I first came in [to recovery]. Obviously, I don’t go to as many meetings, but still go to meetings on a regular basis
JB: Do you have any regrets about either type of treatment? The forty-two day inpatient or the methadone?
KS: I do believe that in my case, I needed to be taken away from my environment, simply because of the people I was associated with. That’s not the case for everyone. In my case, I needed to be away from my environment. So the detoxing from the methadone and going into a residential program, that’s what worked for me. Obviously, people can do that other ways. But I still had people in my life that were negative influences.
JB: If you had an opioid addict who presented for treatment for the first time, what would you recommend? If money were no object?
KS: I’d recommend that individual seek inpatient treatment. Now, if they had an extended history of opiate dependency, then that person’s success rate in residential treatment is obviously going to be limited….and…it would just depend on the individual. Methadone treatment might be the way for them to go. I know that’s kind of teetering on the fence. I’m going to be somewhat….I’m going to hold on to how powerful residential treatment was for me. But I had failed at methadone treatment. And, there again, it was a different time, the methadone doses weren’t enough at the time.
JB: Did you feel normal on your dose of methadone or did you [still] feel withdrawal?
KS: I was feeling normal, however, I could still feel drug use [other opioids].
JB: So it wasn’t a blocking dose?
It was not a blocking dose. You knew if you got medicated at 7:00 am, at 5:00 pm you could fairly well feel somewhat of a rush and feel the effects of [other opioids].
JB: How did you get started working in the field of addiction treatment?
KS: I came out of treatment, worked for a family business for a couple of years, and always, from day one, I thought, “What a fascinating thing….if I could somehow do this…to get into that line of work [meaning addiction counseling].
I started, after two years, as an evening counselor at a residential treatment program, and saw that I really wanted to do that. There was an avenue for non-degreed people to come in to a counselor position. You didn’t have to have a degree in substance abuse or anything like that, so I pursued that, and followed the certification process. I didn’t work in residential treatment but nine months, and then moved to methadone counseling. From that point on, I had found what I wanted to do. And I’ve been offered a promotion at the treatment center to another department when I was over the methadone program, and turned it down to stay with that population [meaning opioid addicts in treatment on methadone].
JB: So you obviously enjoy it.
KS: Oh yeah.
JB: What did you like about it?
KS: I think my ability to relate to that population, without having any thought or putting any real effort…I don’t have to think about it. I know I can talk to that population, and I know I can make them feel normal, by just holding a conversation with them….it might not be about drug use. It might not be about anything pertaining to the treatment episode, but I feel like…that I know exactly where they’re coming from, and I can give them some hope that they don’t have to keep living that way. Just an identification with that population.
JB: That’s a precious gift.
KS: I agree.
JB: Do you believe that your background in addiction helps you when you talk to patients?
KS: I do. I believe wholeheartedly that you can’t teach that. I’ve had some people work for me who had a graduate degree, have never personally had an incidence of opioid addiction or any addiction in their family, and they’re absolutely fantastic clinicians. And you know they’re in that line of work for a reason. So [personal experience with addiction] does not need to be a criterion; in my case, it helps. I find it fascinating to watch someone work who has no self-history of addiction. They can be very effective.
JB: What are the biggest challenges you face now at your work?
KS: That would be…documentation. [The demand for] documentation in this field has really overcome the interpersonal relationship. I can’t help but think as time goes on, that’s going to continue. We don’t have twenty or thirty minutes to sit down with a client, and get into one issue after another, or whatever [the client] may have on their plate. And in opioid treatment, a lot of times it’s brief therapy. They [patients] don’t want to talk to you for twenty or thirty minutes. But you don’t have time to do that, because of the documentation. [The counselor has] three people waiting in the lobby, and you’re kind of selling that person short.
The documentation standards continue to rise, and in methadone treatment, I don’t know how that can go hand in hand with a fifty to one case load. Whereas, someone else might have the same documentation required in the mental health field, but they might have sixteen people they’re seeing.
JB: So you’re saying that the state and federal regulations about documentation actually interfere with the amount of counseling the patients get?
KS: Right. Right.
JB: That’s sad.
The clinic where you work has eight different sites. Can you tell me about what sort of interactions you’ve had with the community leaders, local police, and medical community?
KS: Overall, with any opioid treatment program [methadone clinic], there’s going to be a negative stereotype associated with it in the community, as you well know. Local law enforcement has a bias [against] the [methadone] program. What we’ve found is, any interaction we have with them, and the better understanding that they have [of what we do], the better. And I believe we can make a difference in what law enforcement, and other areas of the community [think about methadone programs]. It’s going to have to happen one person at a time.
An example of that would be when I got a call, a couple of weeks ago, to one of the clinics at ten o’clock at night. An alarm is going off. So I meet the police out there, and we go in, make sure nobody’s in the building. I’m trying to give him some information about it [the methadone program].
He says, “Is it true they come in every day and ya’ll shoot ‘em up?” (laughter) So he thinks that’s what happens.
So, I educated him on what we do and followed that up with, “Why don’t you stop by and get coffee any time you want to and we’ll give you information.” They were very receptive to that. That’s how you’ve got to approach it. Be willing to talk to people and give them information. [Do the] same thing with community leaders. They’re just not educated in outpatient opioid treatment. Once they get some information, they seem to have a different take on it.
JB: Can you tell me what you’ve seen, particularly over the last seven years, about the types of populations that are coming to the clinics, and if that’s changed any?
KS: I started working in methadone treatment seventeen years ago. We used to have statistics on the methadone program. The average age of a person coming on the program was thirty-four years old, at that time. We had eighty or ninety people on the program and that was it. And they were long term users, primarily heroin as drug of choice. We’ve seen what’s happening over the years.
Heroin has decreased somewhat. Prescription medications went wild. I just read information that forty-four percent of patients entering methadone programs in the nation were on prescription opioids. The age of the person coming on the program has dropped from thirty-four into their late twenties. I don’t have that exact number. But we’ve seen them get younger, and we’ve seen prescription drugs take the place of heroin, in driving people into treatment.
JB: What seems to be the main type of prescription drug, or is there one?
KS: OxyContin changed the landscape in our setting. It’s still a driving force, as far as putting people into treatment. We have an increase in heroin here, but the western part of the state…OxyContin and morphine are on the scene….and any painkiller.
JB: Do you have any opinion about why that happened? Why the incidence of pain pill addiction seemed to rise over the last seven to ten years?
KS: If there’s a reason for it….I think it’s generational. It’s passed down. It’s easy. You’ve got doctors giving the mother and the father painkillers for whatever reason, legitimate or not. It gets passed on…obviously there’s a genetic link for some kinds of addiction or alcoholism. I think you know what you’re getting there [meaning a prescription pill]. People addicted to opioid drugs have very few avenues to get quality heroin in those regions of the country. [Pain pills] are a sure bet. Patients say, “I know what I’m getting when I get that pill.”
JB: If you had the ear of policy makers in Washington D.C., what would you tell them? What would you like to see happen in the treatment field for opioid addiction?
KS: I’m going to refer back to what I said earlier. In methadone treatment, there should be some kind of review, as far as what needs to be documented. Obviously, there needs to be accurate documentation, but not to put methadone or opioid treatment into the same mental health arena for documentation requirements. Because you’re dealing with a different environment, a different population, and a different caseload.
JB: Would you like to see buprenorphine play a role [at the methadone clinic]?
KS: Yes, there’s a need for it. You’ve got such a stereotype against methadone facilities, that’s another avenue for people to be in treatment [meaning buprenorphine]….whether it’s administered in the methadone facility or [community] doctor-based, there’s a need for that.
This interview was with one of the many wonderful people I’ve had the honor of working with at methadone clinics. In my years of work in the medical field, I’ve never been surrounded by as many quality people, who had passion for their work, as I have in addiction medicine. I don’t know if I’ve been extremely lucky, or if all addiction treatment centers draw dedicated individuals to work within their systems. Many of these workers try hard to dispel the stigma and social isolation that addicts feel.