Archive for the ‘Relapse’ Category

Insurance Companies Behaving Badly





Another one of my patients was denied coverage for his buprenorphine treatment because he’s still using marijuana.

I’ve written about this kind of situation before, and I have mixed feelings.

It was time for me to fill out this patient’s prior authorization form, which must be completed every year, before for the insurance company will agree to continue to pay for his Suboxone. Among other questions, the form asked if all the patient’s urine drug screens have been negative for illicit drugs. Much as I personally may be tempted to answer “No” in order to save the patient some aggravation, that would be a lie. I’m not willing to commit insurance fraud, so I answered honestly. In the insurance company’s eyes, this means my patient is noncompliant with treatment.

Last year, we had no problems. I answered all the questions the same as this year, but I suspect insurance company workers inadvertently overlooked my answer. Not this year. We got news that the prior authorization was denied, and I suspected the positive drug screens were the reason.

We called his insurer, and had a devil of a time confirming that. At first, insurance company personnel said I hadn’t provided all the information that they needed to make a decision. We persisted, and another worker said she’d already talked to my female nurse about what information was missing.

That’s a pretty good guess, since most doctors’ offices have female nurses, but I don’t. I am the only female working at my practice, and I did not talk to them.

It was a bold-faced lie. When asked what number she had called to talk to the non-existent nurse, she recited our fax number. That’s when we told her it would have been a hell of a trick to talk to an imaginary nurse on a dedicated fax line.


Eventually, of course, the insurance company said ongoing use of marijuana constituted non-compliance with treatment and they were no longer going to pay for my patient’s Suboxone.

Putting the insurance company’s incompetence and dishonesty aside for a moment, not an easy task, I have mixed feelings about this whole issue.

On the one hand, my patient is using an illegal drug (at least in this state). I have talked to my patient numerous times about the reasons I would like for him to quit using marijuana. He smokes several times per week for stress relief. I’ve been working with him, asking him to identify other non-drug ways of dealing with stress. My objections are not completely based on the physical or social harms caused by marijuana, since I agree much less harm is caused by pot than alcohol (which is legal – and toxic to the body’s organs). Still, we know marijuana can cause memory loss and loss of IQ points when used long-term, so neither is it completely harmless.

Marijuana use keeps my patient with addiction in a drug culture. Since being around other people using drugs is a big relapse trigger for many patients, it puts him at risk for an opioid relapse. Some pot dealers have diversified product lines, and sell pain pills as well as marijuana, so that’s also a trigger for relapse. I also believe marijuana use interferes with developing the ability to deal with life without using a pill or a potion, which is the biggest chore of recovery. Use of marijuana also impairs judgment. My patient, under the influence of THC, could think using opioids was reasonable.

But on the other hand, this patient has made such large improvements in his life. His marijuana use hasn’t caused the chaos in his life that use of other drugs has caused. During the seven years he’s been in recovery, he has made tremendous improvements in his life. He works full-time, takes care of his children, and is involved in their after-school sports. He pays taxes, and is a fully functioning citizen. He would make a good neighbor and a good friend.

He pays a big insurance premium each month, but now they won’t cover the cost of the Suboxone films that I prescribe, because he’s “non-compliant” with this one aspect of his recovery. I don’t have qualms about switching him to the generic monoproduct buprenorphine, because I feel he’s at low risk for misuse of his meds, so that will be less expensive, but still not cheap.

I understand the insurance company’s reasoning. They are saying why should we pay if the patient isn’t willing to be compliant with their own treatment? They may have a point.

However, if they are going to take that position, they shouldn’t be allowed to treat the disease of addiction differently than other chronic disease.

What if my patient were an overweight diabetic? He isn’t, but I’ve treated plenty of them in the past, when I worked in Internal Medicine (or “eternal medicine,” as we called it, because no one EVER got better from their chronic diseases like diabetes, high blood pressure, heart disease…).

How about if my patient was told to lose weight and exercise, but instead he remained sedentary, and actually gained 20 pounds? Do you think it would be reasonable for his insurance company to stop paying for his diabetes medication, saying that he was noncompliant with treatment?

I see no difference between those two scenarios. With both addiction and type 2 diabetes, the patient has to make lifestyle changes for the disease to improve.

Let me give another example. Let’s say I treat a woman with asthma. I prescribe several inhalers to help keep her from having an attack of asthma. I’ve recommended she stop smoking, and she’s able to cut down from a pack a day to a half-pack per day. When it’s time to submit a prior authorization to her insurance company so that they will continue to pay for her very expensive and life-saving medications, do they have the right to refuse to pay for them since she’s still smoking?

I’ll belabor the point. Let’s say I have another patient with chronic back pain. He’s forty pounds overweight, and I’ve recommended weight loss and back exercises for him, along with an expensive anti-inflammatory medication. His insurance company asks if he’s been compliant with treatment, and I have to answer “no” because he has actually gained a few pounds, and admits he rarely remembers to do his back exercises. If the insurance company refuses to pay for the expensive anti-inflammatory that helps with his pain, is that justified, or is it wrong?

Imagine the outrage among patients if insurance coverage was denied for all patients who didn’t follow all of their doctors’ recommendations.

Insurance companies, you may have the right to limit coverage if patients aren’t doing what they need to do for treatment of their chronic ailments. But it shouldn’t be legal for you to pick and choose which diseases you use this approach for.

In fact, didn’t the Mental Health Parity and Addiction Equity Act of 2008 require insurers to have treatment limitations be no more restrictive for mental and addiction than for other illnesses?


Split Dosing of Methadone May Reduce NAS


I just read a new article (McCarthy et al, Journal of Addiction Medicine, Vol. 9, (2), pp105-110, March/April 2015) on methadone dosing during pregnancy. This study’s data showed reduced incidence of withdrawal in babies born to moms on divided doses of methadone compared to once-daily dosing. This data also showed reduced incidence of withdrawal in these moms on higher total doses of methadone compared to what we have seen in the past with lower maternal doses.

Current practice is to adjust the maternal dose of methadone according to how she feels. If she has withdrawal signs and symptoms, we increase her dose. We assume that if the mother’s at an adequate dose, the fetus should be doing OK too. We know reduced dosing of methadone during pregnancy is not recommended due to higher relapse rates in the mom, and worse fetal and maternal outcomes. Additionally, past studies showed no clear relationship between the maternal methadone dose and the likelihood of neonatal abstinence syndrome (NAS). In other words, increased maternal dose doesn’t increase the incidence or severity of withdrawal in the newborn.

However, we also have past studies which showed a significant decrease in fetal heart rates and fetal movement during times of peak methadone levels (several hours after dosing), compared to fetal heart rates and movement during times of trough blood levels (end of the 24-hour dosing cycle). Those studies showed more normal fetal heart rates and movement after splitting the total dose into equal doses, which is called split dosing. Due to this data, many opioid treatment program doctors have been trying to split the mom’s total methadone dose into two halves, a morning and evening dose.

The authors of this new study decided to build on past data and look at more than once-daily dosing of methadone during pregnancy. They also increased the total dose of methadone to treat any maternal report of withdrawal.

The study is a bit complicated. It was a retrospective chart review done in an eight-hundred patient opioid addiction treatment program in California from June 2008 until January 2013. The study followed sixty-two pregnant patients who were 83% white, 13% Hispanic, 2% African American, and 2% Asian. Of these sixty-two patients, 71% used primarily prescription opioids and 29% used mainly heroin. Some of these patients were already pregnant when they enrolled in treatment and some (32%) became pregnant after starting treatment with methadone. Sixty-six percent of these patients were smokers.

All the patients were moved to twice-daily dosing within several weeks of entry into treatment. Subsequent increases and further dividing of maternal dose was determined by maternal report of opioid withdrawal, and on methadone trough blood levels. All efforts were made to maintain maternal blood level in the “therapeutic range.” Most women dosed three or four times per day by the last trimester, and the average maternal dose at delivery was 152mg per day.
The highest dose in this study was seen in a pregnant patient who was a fast metabolizer of methadone. She required a total dose of 415mg, which was split into six doses. Interestingly, her infant did not need treatment for NAS.

The outcomes of the study were unusual in several ways.

Of the fourteen hundred urine drug screens collected on these pregnant patients, 88.4% were negative for illicit drugs. The mean gestational age was 38 weeks, and only 18% of the babies were born before 37 weeks gestation.

But here is the most noteworthy finding: only 29% of the babies had neonatal abstinence syndrome (NAS) that was severe enough to need treatment. As in other studies, this study showed no correlation between maternal dose and the incidence of NAS.

In the past, the incidence of neonatal withdrawal syndrome has been estimated at 60-80%, though the MOTHER study of 2010 (Jones et. al) found 50% of infants born to both moms on methadone and moms on buprenorphine had withdrawal that was severe enough to need treatment. (That study also found infants born to moms on buprenorphine stayed in the hospital half as long as babies born to moms on methadone, and also had much less severe NAS.)

In this present study, the babies conceived during methadone treatment were not significantly more likely to have NAS than the babies born to moms who conceived prior to entering medication-assisted treatment with methadone.

Male infants were a little more likely to need treatment for NAS than the females.

The authors concluded that divided methadone dosing and adequate methadone dosing during pregnancy increased maternal recovery and resulted in less stress on developing fetuses. The authors postulate there was less sensitization to repeated episodes of intrauterine withdrawal, which ultimately resulted in much lower rates of neonatal abstinence syndrome.

The authors also identified some limitations of their study, and recommended further investigation.

Over the last few years, doctors in North Carolina have been trying to do split dosing on pregnant women when possible. To do this, the woman must be stable enough to manage the second half of the dose, given as a take home. If there’s an addicted male partner at home, that second dose may fall into the wrong hands, and the pregnant patient can get shorted part of her dose. That’s not a good thing during pregnancy, so it’s all about balancing risks with benefits.

This is an intriguing study, but it’s probably too soon to change what we are doing in OTPs. I know I’d like to hear how ASAM experts interpret this information.

The information in this study was gleaned from a retrospective review of patients, which may not be as good a study as a prospective double-blind study, if such could be conducted.

I’m impressed with the 66% smoking rate. I estimate that around 95% of pregnant patients at the OTPs where I work are addicted to nicotine. But I live in a tobacco state, and the study, done in California, has fewer smokers. I think that might be a significant difference, because we know NAS is more like to occur in smokers. Did that play a role in the lower NAS incidence found in this study?

Did the authors of this study take any extra measures to ensure their pregnant patients were living in a safe environment, conducive to recovery? Are the authors sure their pregnant patients were able to consume all of their take home doses? Were any doses diverted, willingly or unwillingly, to other people? Sometimes female patients live with partners who are also addicted, and the patients may be tempted or coerced into giving a dose to a partner in opioid withdrawal. If this happened it could change conclusions of this study.

I suspect the average maternal dose in this study was higher than at most opioid treatment programs in my area. As the authors concluded, this likely improved the mothers’ health and outcomes. This study had a very low rate of positive drug screens, so these patients appear to have been doing exceptionally well in treatment. So is it possible that there could be less withdrawal in babies born to moms on higher doses? That seems counterintuitive, but the authors do suggest that could be why they had low NAS incidence.

The pregnant women in this study got more counseling and support from their OTP than may be provided in other OTPs. The patients in this study had a weekly meeting with a pregnancy counselor, weekly group meeting for education and support facilitated by the clinic physician, psychiatric assessment, and monthly supportive psychotherapy. They got weekly urine drug screens, so there was close accountability. They also had methadone trough blood levels drawn when needed.

The study presents intriguing data. We need more information, more studies to see if higher and divided methadone doses will provide better outcomes with less NAS, as was seen in this study.

Suboxone: Miracle Drug or Manacle?

Yesterday in my office, I saw patients for whom I prescribe buprenorphine (better known under the brand name Suboxone). It was not my typically pleasant day. Usually, I see the positive changes occurring in the lives of my patients: they are getting families back, getting jobs or better jobs, getting health and dental care needs addressed, and overall feeling happier and more productive.

 But yesterday I had two patients who were bitter about being on Suboxone. Both were having great difficulty tapering off of Suboxone. Both had also been reading materials on the internet that described the hopelessness of ever tapering off this medication.

 This frustrates me for several reasons. First, not everything you read on the internet is correct. Second, people don’t appear in my clinic requesting Suboxone for no reason. All of my Suboxone patients were addicted to opioids before I ever prescribed Suboxone. Even assuming no patient ever gets off Suboxone, it’s still so much better than what they were doing before. Third, I’ve never said it’s easy to get off Suboxone. It can be done, but it’s still an opioid. When you stop opioids, you will have withdrawal. There’s no way around that. 

Overall, most people say withdrawal off Suboxone is easier than other opioids. But people and their biochemistries are different, and I accept that some people have a worse withdrawal than other people. I’ve had a few people say methadone withdrawal was easier than Suboxone withdrawal. I have to believe that’s their experience, but I think that’s unusual, and not the experience of most people. 

Some doctors think patients on maintenance medications, like methadone or Suboxone, should always stay on these medications, given what we know about the rates of relapse and even death for patients who leave these programs. And some patients have continued sub acute withdrawal symptoms for weeks or months off opioids, and just don’t feel right unless they are on maintenance medications. These people seem to do better if they stay on maintenance medication. 

And on the other hand, many people are able to taper off opioids and remain off of them, and lead happy, healthy lives. I keep thinking about two groups of recovering opioid addicts who do well off of all opioids, on no maintenance medications: members of 12-step recovery groups, and recovering medical professionals.

 Off the top of my head, I can think of a dozen recovering opioid addicts who are members of Alcoholics Anonymous or Narcotics Anonymous, and who aren’t on any maintenance medications. They feel fine, and have been abstinent from opioids for years. If you don’t believe me, go to an open Narcotics Anonymous meeting. Ask the recovering addicts there if they have been addicted to opioids in the past. Chances are that around a fourth of the people you talk to are recovering from opioid addiction. There may be a few people who are on methadone or Suboxone, but many are completely free from opioids.

 Look at doctors in recovery. Opioids were the drug of choice for many addicted doctors, and they are “real” addicts, having used remarkable amounts of opioids before getting into recovery. But doctors have one of the highest rates of drug-free recovery. This isn’t because we are so smart or special, or because we have Charlie Sheen’s tiger blood. It’s because we are held tightly accountable by our licensing boards. If we want to practice medicine, we have to participate in recovery. Licensing boards often hold our licenses hostage unless we do the work of recovery. This may mean three to six months of inpatient residential treatment, after a medical detoxification. It may mean four recovery meetings per week for the first five years of recovery, along with monthly random drug screen, and a monitoring contract for five years.  (1,2)

If every addict seeking recovery could have that degree of treatment and accountability, I suspect relapse rates would be uniformly low. Sadly, that’s just not possible for most opioid addicts, because of financial constraints, and because there’s less leverage with most people than with licensed professionals. 

Not all opioid- addicted doctors do great off opioids. Many have multiple relapses, and would probably be much healthier and happier if they got on maintenance medications like methadone or Suboxone, but isn’t allowed – at present – by the licensing boards in most states. Again, one type of treatment doesn’t work for everyone.

 My point is that it is possible for many people to get off Suboxone, and live a happy drug free life. And for other people, lifelong maintenance is probably the best and safest option. At present, we don’t have a way to predict who might do well off of Suboxone (or methadone). We do know that a taper should be slow, and probably takes four to six months for a taper to give best results.

 I believe in Suboxone. It’s saved many lives, just like methadone has. I wouldn’t prescribe it if I didn’t know it works. I think what I’ve been hearing and reading is a normal backlash against the unrealistic expectations many people had for Suboxone. It’s been called a miracle drug, but it’s not. It’s still an opioid, and there is still a withdrawal when it’s stopped. It’s a great medication for many people. It can allow many opioid addicts to get their lives back and enjoy a normal life, except for having to take a daily dose of Suboxone. But isn’t that still drastically better than active addiction? 

  1. Ganely, Oswald H, Pendergast, Warren J, Mattingly, Daniel E, Wilkerson, Michael W, “Outcome study of substance impaired physicians and physician assistants under contract with North Carolina Physicians Health Program for the period 1995-2000,” Journal of Addictive Diseases, Vol 24(1) 2005.
  2. McLellan, AT, Skipper, GS, Campbell, M, DuPont, RL, “Five Year outcomes in a cohort study of physicians treated for substance abuse disorders in the United States,” British Medical Journal,2008;337: a 2038.

Use of Prescription Monitoring in Suboxone Patients

I enthusiastically use my state’s prescription monitoring program. This database is available only to physicians who have applied and been approved for access. It records all controlled substance prescriptions filled by a patient, the prescribing doctor, and the pharmacy where they were filled. This means it records prescriptions for opioids, benzodiazepines, anabolic steroids, most sleeping pills, and prescription stimulants. Any prescription medication with the potential to cause addiction will be listed. Medications such an antibiotics, blood pressure medication, etc, aren’t controlled substances, and aren’t list on the website. 

I use this database in several ways.

It can help me decide if a new patient is really addicted to opioids, and appropriate for treatment

If a new patient has a urine drug screen that’s negative for all the opioids, and has no record of getting prescriptions for opioids, I’ll have to see objective evidence of addiction before starting to treat him with Suboxone. But if the urine is negative, and I see monthly oxymorphone prescriptions (sometimes missed on urine drug screens) have been filled, it’s more likely this patient is appropriate for Suboxone treatment. Rarely, a misguided, misinformed person might claim to be addicted to opioids in order to be prescribed Suboxone. This happened once to me, with a patient who was addicted to Xanax, and was convinced Suboxone would cure her. I referred her to more appropriate care.

Using the database can help detect a relapse sooner

Most of the patients in my Suboxone practice (around 80%) are pill takers, not heroin users. When they relapse, it tends to be to prescription opioids, obtained from a doctor unfamiliar with their history of addiction. I check each patient on the state’s database just prior to each visit, and if there are medications on the site I didn’t know about, that will be the main topic of our visit. New medication on the database doesn’t always mean a relapse, so I need to listen to their explanation.

 When it does mean a relapse, the patient and I decide what to do next. Often, the patient decides to allow me to call the other doctor, agrees to increase her “dose” of counseling, and possibly her dose of Suboxone, if it was an opioid relapse. If there are repeated relapses, I may decide Suboxone, as an outpatient, doesn’t provide the support a patient needs. Then, I refer to another form of treatment. Usually this means to a long-term inpatient drug rehab, or to an opioid treatment center, where the patient comes to the clinic every day. Either way, I believe I’m able to address a relapse more quickly using the database.

 Frequently, Suboxone patients get prescriptions for benzodiazepines. That’s a problem for me. For a person without addiction, benzodiazepines can be helpful, mostly used short-term. But for people with addiction, they usually cause problems, sooner or later. People with a previous addiction to any drug, especially including alcohol, need to regard prescription benzodiazepines as high-risk medications.

 I try to be flexible, too. If a traumatic event has occurred in the life of a patient, I may OK benzodiazepines short-term, provided I can see the patient more often and have good communication with the doctor prescribing the benzodiazepines.

  I also have to remember the body reacts the same to a mixture of opioids and benzos, no matter why they’re taken.  Even though Suboxone is safer than methadone, it’s still not safe when mixed with benzos, when taken for any reason.

If this sounds wishy-washy, that’s because it is. So many situations arise in the lives of patients that one hard and fast rule just doesn’t exist. That’s the art of medicine.

 Is the patient filling Suboxone on time?

The database also shows me when patients are filling the Suboxone prescription. If I write a prescription today, but the patient doesn’t fill it for two weeks, what’s going on there? Has he relapsed for several weeks? Did he have a stockpile of Suboxone from a previous prescription? Was he unable to afford it until now? All these questions and their answers are important to guide treatment.

 It makes me happy.

It warms my heart to see a patient who had a long list of opioid prescriptions from multiple doctors before starting Suboxone, then after entering treatment, see only Suboxone. This occurs in the majority of my patients.

My state’s prescription monitoring program is one of the best tools to help patients that I’ve ever seen. I believe it’s saved many lives. I think it’s just as important as drug screening for my Suboxone patients. Of course, the best tool for recovery is the counseling. I prefer 12-step recovery, as that provides ongoing support even after Suboxone treatment, but any kind of counseling helps. The patients I see doing the best are the ones involved in both formal counseling, in group or individual settings, along with 12-step meetings.

Opioid Blockers: Do They Take All the Fun Out of Life?

According to an interesting article in the most recent copy of the American Journal on Addictions, the answer appears to be, “No,” at least for some people. (1)

 This article described a study where researchers asked patients on the extended-release opioid blocker naltrexone to rate the amount of pleasure they obtained from things like eating good food, sex, and exercise. These patients were on naltrexone for the treatment of alcoholism, but of course, the information may be helpful for opioid addicts who are treated with opioid blockers to prevent relapse back to opioid use. The subjects were asked to rate, on a scale of 1 to 5, the amount of pleasure they obtained from activities such as sex, eating good food, exercise, talking with friends, and other usually enjoyable things in life. A score of 1 meant they felt no pleasure at all, and 5 meant they felt much pleasure.

 The good news is that pleasure scores for these patients were relatively high. For example, the average score for pleasure from eating good food was 4.14, out of a possible 5. For listening to music, it was 4.00 out of 5. For sex, it was 3.92. For drinking alcohol, it was only 2.57 out of 5, which supports the use of this medication for alcoholics.

 In summary, the study found that subjects on extended-release naltrexone still experienced a good amount of pleasure from life.

 There were limitations to this study, however. We don’t have a pre-naltrexone baseline for these patients. In other words, we know pleasure ratings were fairly high while on naltrexone, but it’s possible these subjects had even higher pleasure scores before naltrexone. Also, there was no placebo control in the study. Maybe people getting pretend, or sham, treatments would have had higher pleasure scores, but we don’t know. 

In my mind, the biggest weakness was that the study enrolled 187 patients, but only 74 completed the intended survey. That means about 60% of the subjects dropped out of treatment, and the article doesn’t say why they dropped out. Maybe the drop-outs were the ones to feel a lack of pleasure in their lives from being on naltrexone, and the ones who stayed on it didn’t have this same side effect. If so, this would obviously skew the results.

 But even with these admitted weaknesses, and even though the study was paid for by the company that manufactures the sustained-release naltrexone (Vivitrol), this article gives hope that Vivitrol may work for opioid addiction. It may help prevent relapses, without interfering with life’s pleasures. And we need every tool we can get to fight addiction.

  1. 1.      O’Brien, Charles; Gastfriend, David; Forman, Robert; Schweizer, Edward; Pettinati, Helen, Long-Term Opioid Blockade and Hedonic Response: Preliminary Data from Two Open-Label Extension Studies with Extended-Release Naltrexone, American Journal on Addictions, Vol. 20 (2), March/April 2011, pp106-112.

The Story of a Recovering Addict

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: Wow

KS: Yeah.

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.

Bibliotherapy: More Addiction Memoirs

If I Die Before I Wake, by Barbara Rogers

Anyone struggling with addiction to drugs including alcohol can get something out of this book. The author describes what her addiction was like, what happened to get her into recovery, and what it’s like now. And she went further than that. She described the trials she faced while in recovery, and how she applied the spiritual principles of the twelve steps as she went through these trials. This book is like going to a really good speaker meeting. It will resonate with both newcomers and old-timers in recovery. I will be recommending it to my patients.

Pill Head, by Joshua Lyons

I was envious as I read the book, because he did such a great job of writing an interesting, engaging book, while also educating the reader with (mostly) accurate facts about the disease of opioid addiction. It’s more interesting than my own book, Pain Pill Addiction, though I have more science in mine. Anyway, the author shows the dividedness of many addicts. He wants to be in recovery, and hates the negative consequences that are occurring as a result of his addiction, but he still wants to use pain pills. I don’t think people newly in recovery should read it because it may trigger cravings in the places he describes drug euphoria. His story isn’t one of hope, and I wish he’d waited until he was further into recovery to write the book.


Loaded, by Jill Talbot

            Ugh. I didn’t like this book. It was false advertising, for one thing. It was more about her unhappy love life than it was about her alcohol addiction. For the first two-thirds of the book, she laments about how dating married men made her lonely. Duh. Then toward the end she does talk of some sticky situations due to alcohol, and describes her fellow patients at a drug rehab. But then she is vague about her relapse back to drinking, and if she was able to do controlled drinking, or if she went back to her former state.

Wired: the life and Fast Times of Jim Belushi, by Bob Woodward

            It could have been cut in half and been a much better book. The renowned author put in a great many details of the days and nights during the years leading up to the star’s death from drug overdose, and it felt like too much after a few chapters. We get it. He was a wild and crazy guy. He did outrageous things and was tremendously talented and deeply flawed. Maybe knowing the ending made it sad from the start. Another big talent obliterated by addiction.

Broken, by William Cope Myers

            He’s the son of the famous journalist William Myers, and now a spokesman for Hazelden recovery center in Minnesota. This memoir is one of the better ones. He does a good job of describing the guilt that comes after a drug binge, and about his family’s disappointment in him. With a famous father, the press of expectations was an added stress that may have pushed his addiction further.

Go Ask Alice, by Anonymous

I came across a paperback copy in a bargain bin at a thrift store, and bought it to re-read. I read it as a teen, and at that time suspected it was written by an adult to scare kids away from drugs. I wondered if I’d think differently reading it as an adult. I didn’t. I certainly didn’t sound like it was written by a fifteen year old. It’s a fair book, but probably fictional.

Can’t Find My Way Home, by Martin Torgoff

I’ll re-read this one. It’s a comprehensive history of drug addiction in the U.S. from 1945 until 2000. Focused on the various political movements and popular trends of different years, it puts drug use into cultural context. It also gives some specifics behind some famous drug users and drug legalization proponents. It was fascinating. At the end, the author unexpectedly described his own recovery. Anyone wanting to read more about the 1960’s and 70’s drug culture should read this book.

“The End of My Addiction,” by Dr. Oliver Amiesen

            I only got this book because a few patients mentioned it. I pre-judged this book, thinking the author must be a pompous doctor, hater of Alcoholics Anonymous, who wrote a lame book on a half-baked theory about addiction treatment, just for his self-glorification. I was completely wrong. The author writes about his own addiction with self-awareness and humility. He doesn’t claim to have all the answers, but presents a credible treatment that may benefit alcoholics. He started himself on high-dose baclofen, a muscle relaxant that’s been around for years. It quenched his thirst for alcohol. He presents a good enough argument to justify a large randomized controlled trial to test the theory that high-dose baclofen suppresses alcohol cravings. The book is well-written and interesting. Dr. Amiesen describes his own travails with addiction in some detail.


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