Methadone Today

Report from our Nation's Capitol - Chris Kelly, Director DC-ARM

Rocco's Story - Rocco

Insurance Claims

Answers to Frequently Asked Questions about Hepatitis C

Doctor's Column -
Taking Extra Methadone & Proper Dosing / Methadone & Depression - Feb. 2000, Vol. V, No. II

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Advocates for Recovery Through Medicine (ARM) is a nonprofit organization that advocates for reform of pharmacological treatments* for opiate addiction at the policy level.

 In the capitol of the world's most prosperous country, thousands of heroin addicts are dying.  Despite the District government having a so-called "Addiction Prevention and Recovery Agency" (APRA) with a 32.2 million dollar annual budget, the waiting list for methadone maintenance treatment (MMT) has had more than 1,000 persons for over two years.  We have been promised a new 410 patient MMT clinic for the past year; every month we are told, "it will open next month," and  the last word from APRA is that the contractor is asking for too much money per patient, so the contract has to be renegotiated.

 In a city with approximately 16,000 intravenous drug users (IVDUs), only about 1,000 [6.25%] are able to access the best treatment for opiate addiction--methadone maintenance.  And those patients who are able to access APRA MMT clinics are treated to one of the worst clinic experiences in the USA.  Low doses, observed urinalysis [urine testing], punitive policies, very restrictive take-home rules, dirty bathrooms, unfeeling counselors, unreasonable dosing hours, anything that makes a bad clinic, can be found at the APRA clinics.  It is a miracle that anyone finds recovery here.

 What is going on?  Part of the problem goes back to the city's budget crisis of the mid-1990's.  Six years ago, there were seven public MMT clinics; now there are three, with one dedicated to women of childbearing years only.  Turnover in top management at APRA did not help.  The latest APRA director quit last week after one year on the job, citing "problems with the city's rule that top officials live in D.C."

 Insiders believe her resignation stems from problems with her staff.  They just would not do what she wanted them to do.  Three of her top aides have also "resigned" or been "reassigned" in the past week.

 The new Director of Public Health, which oversees APRA, promises to "rebuild the agency from the ground up."  A major part of this rebuilding will be passage of the "Freedom in Drug Treatment Act", which will change APRA from a service provider to a gatekeeper, where they will evaluate patients and then allow the patient to choose the treatment they desire.  APRA will certify the treatment providers and also oversee a proposed budget of approximately $10,000 per patient per year for treatment services.

 If this bill passes, it will be a gold mine for treatment providers and could open the treatment community to competition--something that is sorely needed here.  And it will provide money, another sadly lacking component in today's MMT system.  The public clinics charge a sliding scale from $1-5 per day.  But they are not equipped to take Medicaid or any other insurance that will pay for MMT.  The two private clinics charge $105 per week and $10-15 per day respectively, which is way out of the reach for most D.C. addicts.  If passed, this new bill will provide enough money to treat anyone who wants MMT.

 But this bill does nothing to address the problem of access.  Because of Not in My Backyardism (NIMBY) and the terrible reputation of the existing APRA MMT clinics, even the most drug devastated areas of the city are loathe to have a treatment clinic open in "their neighborhood."  The APRA MMT clinics' bad reputation is well deserved; it is a veritable drug store outside the so-called Model Treatment Clinic—even the clinic director jokingly calls the intersection "New York General" because so many street doctors practice there.  Because of these problems, the city council should look seriously at community pharmacy prescribing, where patients could be dosed daily at participating community pharmacies; office based treatment, where stabilized patients could be given 30-day prescriptions in a regular doctor's office; and methadone buses, which are currently used in Seattle, where buses go to different areas of the city and dispense only.

 As a twenty-year veteran of the D.C. public MMT system, I am more than ready to see changes.  I have seen too many friends, family members and acquaintances die from this disease.  Washington, D.C. has the highest rates of HIV and HCV [the virus that causes Hepatitis C] in the country, yet this lifesaving medication is still unavailable to thousands that need it.  We hope that the passage of the "Freedom in Drug Treatment Act" will be the beginning of hope for the still suffering among us.

Note: *In this context, "pharmacological treatment" refers to treatment with opiate agonist or agonist-antagonist medications.  In the U.S., the only opiate agonist medications approved for opiate addiction treatment are methadone and OrLAAM.  Buprenorphine, an agonist-antagonist medication, has not yet been approved for opiate addiction treatment by the FDA but has been used for this purpose for a few years on a research basis.
 
 

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 About two years ago, because of the expense of methadone maintenance treatment, I was forced to come off of it.  Before this, I had tried every  type of detox short of being exorcized by a Priest.  When a friend told me about the Narcan Challenge (ugh), with the Naltrexone program to be administered after the challenge, it all sounded too good to be true.  Which it was!

 The first thing this nurse (the Nurse Ratchet type) did was to approach me with two shots full of Narcan.  She hit me once in each arm, intramuscular.  She then stepped back quickly as if I was going to turn into Mr. Hyde.  I asked her why she stepped back so quickly.  She smiled and said, "Well, people have different reactions, and sometimes they get very angry".  I had NO IDEA what I was in for in the next hour.

 Within five minutes, every muscle in my body was contracting, I was sneezing uncontrollably, eyes watering, puking, and gasping for air.  And through all of this, I remember her saying in a sweet little voice, "I wish I had a camera to show kids what drugs do to people."  If I had had the strength I would have stuck her head in the toilet and flushed it.

 Then, in came the doctor.  He watched me for the next hour writhing with cramps, throwing up, cold sweats, etc., the works.  And he sat there with a little notebook.  Before he would even administer any drug of relief, he told me he had to study my symptoms.

 It did not take a rocket scientist to figure out I was in severe withdrawal.  Finally, an older nurse who had some experience came in and looked at my skin.  Now I don't know what she saw, but she told the doctor, "This man cannot have any food or oral medication.  He needs a suppository or an injection.  He is totally dehydrated from throwing up and diarrhea.  He needs an IV to begin pushing fluids back through his body."

 Finally, after three hours of this hell, they gave me a Compazine suppository.  And still, every four hours, they gave me Naltrexone (and they wondered why I couldn't keep anything down).  I had finally been pushed to the edge. I told them I could not take anymore of their Naltrexone because not only would it not stay down, but I was getting sicker and sicker each time.  It is a good way to lose weight quickly, but I wouldn't recommend that treatment to anyone else—not even my worst enemy.

 Now if I need to see a doctor, I am very leery to tell him/her that I am on methadone maintenance because of the subhuman treatment (at least in this part of the country—northeast) received when they have this knowledge.  I had a doctor outright tell me that because I was on methadone maintenance, I didn't need any type of pain medication, that methadone would take care of any pain I had.  And they wonder why we leave out the methadone when we are in the ER and they ask what medications we are presently taking.

 If there is any way you can spread the word about the Narcan Challenge--please--I urge you to do so.  You can use my story if that helps in any way.

Editor's Note:  Apparently, Rocco was initially led to believe that the "Narcan Challenge" is a detox procedure when, in fact, it is only used to determine whether an individual is opioid dependent.  In this procedure, the patient is administered a small dose of an opiate antagonist—if the patient is opiate dependent, withdrawal symptoms will be immediately apparent.  Repeated administration of opiate antagonists is not necessary to determine opiate dependence, nor is it helpful in determining what or how much medication should be used to assist detoxification.  Thus, if Rocco was administered opiate antagonists to determine opiate dependence, the doctor was clearly incompetent and doesn't belong in the addiction field.

 The other possibility is that opiate antagonists were being used for the purpose of precipitating detox—a form of rapid detox.  Using opiate antagonists for detox purposes is only approved or [somewhat] accepted as a medical practice, when antagonists are administered while the patient is under sedation or anesthesia.  Without sedation, the patient would not be able to tolerate the severe withdrawal syndrome triggered by the antagonists.  At the least, attempting to detox a patient in this manner would constitute malpractice.

 In any case, at best, these medical professionals were incompetent and extremely insensitive; at worst Rocco was being used as a guinea pig.  Thus, the treatment Rocco received is not acceptable and certainly not an approved or accepted treatment.

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 But first, it is worth noting that in some cases, the treatment provider will send a bill directly to the insurance company and then the insurance company or treatment provider will bill you for the portion not covered.  Some insurance companies will handle it in this manner—if the treatment provider is willing to send the bill or work directly with the insurance company.

 Where such arrangements do not exist, you will have to send in a claim yourself to be reimbursed for the amount your insurance will cover.  Some insurance companies require that you get a treatment  "pre-approved", so you will still want to contact the insurance company beforehand to insure that they will cover the treatment.  At this time, you can also get instructions on how to submit a claim and get reimbursed for the cost of treatment.  Also note that some insurance companies will want to talk to your counselor before agreeing to cover the treatment.  For that matter, some insurance companies will only cover the treatment if your counselor has a master's degree, so asking what credentials your counselor must have beforehand is a good idea.

 Different insurance companies may each have their own procedures for submitting a claim for reimbursement.  Some may have their own forms for you to fill out, and others may require you fill out a standard claim form.  Generally, these forms contain directions and are fairly easy to fill out.   Primarily, these forms simply ask for basic information, but read carefully, as claim forms often ask for information about both the patient and the insured/policyholder, since the patient may be a spouse or dependent [or domestic partner, if covered] of the insured individual.  A claim form may also request information contained on your insurance card (i.e.:  a contract number).

 In many cases [including with the standard claim form], your clinic doctor, counselor, or billing person will have to fill out part of the form; after they have filled out the appropriate portion of the form, verify that the doctor and/or counselor have signed it in the proper space.  Finally, remember to sign the form in the space provided—and, if required, also make sure that the insured/policyholder signs the form.

 Normally, insurance companies will require an "itemized bill" be sent with the claim form.  If your insurance company has not specifically requested an itemized bill, you may want to ask them if they need it.  To obtain an itemized bill, you simply need to request one from your treatment provider/clinic.  Your treatment provider might charge for it, in which case, it would not hurt to ask your insurance company if they will reimburse you for the cost of the itemized bill.  If your treatment provider charges for an itemized bill, you might want to find out whether the charge depends on how many weeks or months of treatment are to be listed on the itemized bill (e.g.:  will your treatment provider charge the same amount regardless of the time period documented in the itemized bill, or will your treatment provider charge more for an itemized bill covering a longer time period).  If your treatment provider charges a flat amount for each itemized bill regardless of the time period documented, you might want to file a claim less often to limit the amount you are charged for itemized bills (i.e.:  you file a claim every 3-4 months, instead of once a month, so you don't need itemized bills as often); however, before you do this you should check with your insurance company to make sure that it is okay to only make a claim every few months.

 Although it is not the patient's responsibility to fill out or print out an itemized bill, it is helpful when making insurance claims to know what information is required in an itemized bill and to decipher what various items and codes stand for.  Much of the itemized bill is self-explanatory (date of service, charge, payment).  To be accepted, most insurance companies require the proper diagnosis code and treatment codes.   Normally, itemized bills will have a description accompanying the treatment code, but it is helpful to know what codes to look for.  Knowing the treatment codes will help you find out what your insurance policy will cover, if anything, so you don't wind up wasting your time or worse, losing money.  "90862-Medication Management"  refers to doctors' [30-, 60-, or 90-day] evaluations.  "90844-Individual Therapy" refers to a counseling session (group therapy may have a separate code).  You should ask your insurance company which treatments will be covered, as they might not cover a given week of treatment if certain treatment[s] are not received.

 Obtaining insurance reimbursement of methadone treatment is not especially difficult, but some basic information will prevent delays in the reimbursement process.  In addition, asking some basic questions beforehand will reduce the chance of being denied reimbursement because of some technicality (i.e.:  your counselor does not have a master's degree).  Finally, do not assume that your insurance does or does not cover methadone treatment; treatment is expensive, and any amount of insurance coverage would help pay for it.

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 What is hepatitis C?

 Hepatitis C is a liver disease caused by the hepatitis C virus (HCV), which is found in an infected person's blood.  Hepatitis C is a serious disease.  Many people may carry the virus for the rest of their lives.  Infected people can develop liver damage but do not necessarily feel sick.  Even those who develop a persistent infection may not show symptoms until there is severe liver damage.  In some cases, hepatitis C can cause cirrhosis (scarring) of the liver, liver failure and liver cancer over a period of 20 to 30 years.

 Who is most likely to be infected with the hepatitis C virus?

 Anyone can be infected with the hepatitis C virus.  However, people most likely to be infected with the hepatitis C virus include individuals who:  1) had a blood transfusion and/or received an organ transplant such as kidney, lung or heart, before effective screening began in July 1992; 2) have been or are on long term kidney dialysis (hemodialysis); 3) received treatment with a clotting factor concentrate manufactured before 1987;  4)  have ever injected illegal drugs, even once; 5) have had sexual contact with multiple individuals over the course of their lifetime; 6)  have been health care workers with exposure to blood from a hepatitis C infected person, especially through accidental needle sticks; or 7) have ever had a sexually transmitted disease (STD).

 What are the symptoms of hepatitis C?

 The most common symptom of hepatitis C is fatigue; however, most infected people have no recognizable signs or symptoms for a long time,  Some people do experience flu-like symptoms, such as loss of appetite, nausea and vomiting, fever, weakness, tiredness and mild abdominal pain.  Less common symptoms are dark urine and jaundice of the skin and eyes.  The only way to know if you are infected is through blood tests.

 Is Hepatitis C contagious?

 Yes.  Usually the hepatitis C virus is spread from one person to another by direct exposure to infected blood or blood products and contaminated needles or other sharp objects.  Occasionally, the hepatitis C virus may be spread by:

1) an infected mother to her newborn

2) infected household members

3)  sexual contact.

Sexual transmission typically occurs among people with multiple sexual partners or a history of sexually transmitted disease.  HCV transmission is rare among long-term sexual partners who do not have other sexual contacts.
 If you are infected, we recommend taking extra steps to avoid blood to blood contact with others to prevent any possibility of infecting other people close to you.  Do not share items that may be contaminated with blood such as razors and toothbrushes.  Consider using condoms, because sexual transmission, although rare, is possible.

 What is the Hepatitis C test?

 The human body makes antibodies to fight off all kinds of infections.  Your body creates antibodies to the hepatitis C virus if you are infected with it.  This service tests your blood for these antibodies*.

 Is this test accurate?

 Yes.  In a multi center clinical study this test service*, using blood from a finger stick obtained by non-medically trained participants, was proven to be greater than 99% accurate compared to a blood sample drawn by a medical professional and tested using current test methods.

 It can take up to six months for your blood to develop antibodies to the hepatitis C virus.  [The test] may not detect more recent infections.  We recommend you take the test six months or more AFTER you have been exposed to the hepatitis C virus.

 What does my test result mean?

 There are 4 possible test results:

1) A "negative" test result means antibodies to the virus were not found in your test sample, and it is extremely unlikely that you have been infected [but as explained above, it is possible to test "negative" and have the virus, if infected within six months of taking the test].  [Even] if you receive this test result, you should be evaluated by a physician of your choice if you become ill or if you remain concerned that you could be infected with the hepatitis C virus.

2) A "positive" test result means antibodies to the virus were found in your test sample and that you should consider yourself infected with the Hepatitis C virus.  If you receive this test result, we recommend you consult a physician of your choice for medical advice and follow-up.

3) An "indeterminate" test result means that initial testing of your blood detected antibodies but further testing did not conclusively show that these were antibodies to the hepatitis C virus.  If you receive this test result, we recommend you consult a physician of your choice and/or be re-tested.

4) A "result not available" test result means that the laboratory was unable to provide a result from your sample.  This happens when your test card doesn't have enough blood on it or is wet, soiled, contaminated, or shipped incorrectly.  [This only applies to home tests and can be avoided by following the test's directions carefully].

*"The Home Access Hepatitis C Check" is a hepatitis C test that is bought at a drug store.  A blood sample is taken at home and mailed to a laboratory.  The test is designed to be easy to use and completely anonymous.
 
 

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