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Internet Site Provides Vital Information to International Travelers -
Report States Medical Maintenance Works -
Insurance Coverage: Morality vs. Cost - Aaron Rolnick
Negative Attitudes about Methadone Treatment - the Origin - L.D.
The Problem with Flat Rate Clinic Fees - Author's name withheld by request
Combating the Stigma: Our Responsibility - by Kimberly K. Cole, C.O.T.C
Virginia Considers Rewriting Regulations
Medical Alert Card - Order one today
Doctor's Column - None for
December 2000
The State of Virginia is considering changing its methadone/opiate maintenance treatment regulations. The proposed changes are refreshingly simple and concise. Two of the four proposed alterations deal solely with terminology: using the term “patient” rather than “client” to refer to individuals in methadone treatment and calling the treatment “opioid agonist therapy” (omitting the word “replacement”). The other two items are in reference to the proposed federal regulations; stating that 30-day take-home supplies would be permitted and that state regulations would conform to the proposed federal regulations.
As discussed on page 3, we believe that “patient” is the correct word to describe those in treatment. We also feel that using the term “replacement” to describe methadone treatment misleads many people regarding the nature of said therapy [into incorrectly thinking that methadone is no more than a heroin “replacement”/no better than heroin]. Admittedly, these changes will not make much difference in the actual quality of treatment rendered, but they signal an important change of attitudes - that will hopefully spillover to the attitudes and practices of clinic staff.
The second set of items - if adopted - are far more significant and would benefit many patients, particularly in the area of take-home provisions. As we have explained in previous issues of Methadone Today, states cannot circumvent minimum requirements contained in federal regulations of methadone treatment/opioid agonist therapy, but they can place additional/stricter requirements. Thus, the items dealing with 30-day take-home supplies and conforming to the proposed federal regulations basically mean that Virginia will not place stricter requirements than those contained in the proposed federal regulations.
We believe that the states do not need to place stricter requirements than those in the proposed federal regulations. Obviously, Virginia’s proposal represents steps in the right direction, and we hope that other states will soon follow suit by repealing excessive state regulations and abstaining from adopting new stricter regulations in response to the federal government relaxing certain requirements, especially in the area of take-homes.
It remains to be seen whether Virginia actually adopts these proposed changes and whether methadone clinics in Virginia actually take advantage of them - for example, by providing 14- or 30-day take-home supplies to eligible patients.
Editor’s Note: If you have news about proposed or recently
adopted changes in your state’s opiate agonist treatment regulations, please
let us know by writing to the address at the bottom of page 4 or by sending
an e-mail to: Lmtette@yahoo.com.
Yes! We can and MUST educate law enforcement, employers,
and “do gooders.” We MUST educate the public as a whole.
As a counselor at Cartersville Center, Inc., I feel that it is
our responsibility to do so. Change and educating begins with us.
Talk to everyone regarding the three-fold positives of methadone.
I also believe it is the responsibility of the client themselves. If the client acts/feels embarrassed or ashamed of going to a methadone clinic, what type of response from the public/community can they expect?
To remove the negative stigma, we as counselors, nurses, doctors, and clients must inform and educate the public of “all” the positives methadone has (i.e., reduced crime rates in communities where there are methadone clinics, more stable, employed people due to clients not out chasing drugs, etc.
We, at Cartersville Center, Inc., take this task very seriously. We all know what a difficult job it is finding a happy medium between meeting Federal/State guidelines and being a proactive, client-friendly clinic. That is why our clinic is going out into the public developing marketing tools to educate private sector doctors, employers, and the community as a whole.
Again, I stress that we, the staff and clients alike, must take/make the strides to see change come about. That includes clients sharing/including their families in their treatment. No more deceit or secrets about being on methadone.
In response to your two clients relapsing due to the reverend [see October 2000 issue, bottom of page 1], however, I must say, no one makes anyone do anything. Circumstances help influence our decision making process, but ultimately we are all responsible for ourselves and the choices we make. It is far too easy to blame everyone and everything around us for our relapses. This comes from the ex-junkie in me - not the counselor.
Life has many tragedies; I just lost my fifteen-year-old daughter.
I had to make the decision whether or not to use.
We must all work together and stop making it "us against them."
Change and education will come. Unfortunately, it does not come at
the speed we would like.
Thanks for listening.
Editor’s Reply: First, we’d like to thank Ms. Cole for taking the time to write Methadone Today. We encourage clinic staff and any other interested party to write in. We do print letters and articles from counselors, but we have only printed a small number of items because few write in--not because we elect not to print them.
We believe that a dialogue between patients and staff is important to improving the quality of treatment and educating the general public about methadone treatment. Note that none of the comments that follow are intended to discourage clinic staff from writing in--again, we are glad that Ms. Cole made the effort to send us her comments and concerns, and we welcome the same from any interested party, regardless of their viewpoint.
We appreciate Ms. Cole’s opinion that education about the merits of methadone treatment is important, however, we are distressed that she then talks about “blame” and “responsibility” for what is a disease, not a “choice”, as those comments may lead people to believe.
To use the diabetes analogy, yes, the diabetic has some personal control over his/her disease (taking medication as prescribed, carefully testing insulin levels, and making appropriate dietary choices); however, most people would probably not “blame” a diabetic when his/her disease is not “in control”. Use of the word “blame” suggests that the patient in question made a “bad” decision (by “bad”, we mean “immoral”/in the moral sense).
As long as drug addiction is linked to morality, there will always be a negative stigma associated with individuals suffering from drug addiction--especially methadone patients. The reason methadone patients are so scorned by many is that it is seen as a moral weakness that they need to “substitute” their “immoral” illicit drug use with methadone.
It is one thing to take steps to manage the disease [drug addiction] to try to prevent a relapse; it is another to assess blame or responsibility to an individual who has a disease and has sought help for that disease. Those of us who wish to eliminate the stigma associated with methadone treatment need to change our own ambivalent attitudes regarding drug addiction; we cannot state that drug addiction is a “disease” and then assess blame for a relapse. If addictive drug use is merely a choice--if an individual suffering from drug addiction can merely will not to use drugs, then methadone treatment would not be necessary.
We feel that the reverend was responsible for the relapse of the patients that she forced to withdraw from methadone if they wanted to remain in the shelter she offered. The argument that the patients had a “choice” is similar to the argument employers have made to the effect that employees always have a choice (e.g.: they can quit if they don’t like the job, working conditions, etc.). The fact is that human beings have certain needs, including shelter. The individuals in question obviously had no other option for shelter, or clearly they would have gone to live somewhere else rather than remain at the shelter being provided by the reverend once he required them to detox in order to remain there. We do not know the details, but certainly not having shelter can be fatal: these individuals cannot be blamed for “choosing” to stay at the shelter provided by the reverend rather than risking freezing to death--among the other perils of homelessness.
We believe that it’s a double standard when politicians, for example, complain that, “the elderly should not have to choose whether to buy food or medication (because the price of prescription medication is so high),” but no sympathy is offered for the methadone patient who must choose between food or shelter and the medication he/she needs [methadone]. As for the “choice” to relapse, I’m sure the patients in question did not plan or choose to relapse - it occurred because they were forced to detox off methadone. Thus, we are unsure what “choice” is being referred to and question whether we are really just blaming the victims.
The statements regarding personal responsibility simply do not always hold true. This is evident from the lack of treatment accessibility in the U.S. - individuals suffering from drug addiction may really want to get into treatment and stop using illicit drugs, but they cannot afford treatment--and free or low cost treatment may not be available to them. If we want the public to see methadone treatment as a positive, we must convince them that drug addiction is a disease and that individuals suffering from it should not be blamed for having it.
Finally, we believe that “words do count.” We don’t think it serves methadone patients or methadone treatment well to use the word “junkie” to describe an opiate addict even if we are describing ourselves. We also feel that individuals in methadone treatment should be called “patients” and not “clients.” Methadone treatment is a medical treatment that utilizes medication--a medication prescribed by a physician; recipients of such a treatment are rightly regarded as “patients” and not “clients.” The term “client” diminishes the medical aspect of treatment making maintenance treatment sound like a choice; besides, this distinction is important because “clients” do not have the same rights as “patients” do.
We also do not like the “us vs them” mentality. Many clinics create this distinction by providing poor quality treatment and mistreating patients. We would definitely prefer to NOT have an “us vs. them” situation, but many clinic staff simply do not treat methadone patients the same as other people who have a medical problem--which is how they ought to be treated.
Although we do not know what happened to Ms. Cole’s daughter, we wish to extend our collective sympathy. It is always difficult to lose a child, but one so young is especially a tragedy.
Do you have an opinion on this or any other article printed in
this issue? Write in and tell us what you think!
In the November issue of Methadone Today [see page 2, “Dear Methadone Today”], the issue was raised of whether the cost of treatment should vary based on the dosage of medication. This leads to the bigger issue of the manner in which methadone clinics charge patients for treatment.
At my clinic and probably at most methadone clinics in the U.S., patients are charged a flat rate for treatment - the same amount for all patients. Of course, methadone treatment actually involves a few different services. Some such services are utilized equally by all or most patients. For example, most patients see a doctor every 30/60/90 days for a routine evaluation (how frequently these are given at a particular clinic may depend on state regulations or clinic policy) - only in rare cases would an individual patient receive more frequent evaluations because of some medical circumstance or to satisfy health insurance requirements. Another example of such a service is an annual TB test [often required by state law] or an annual physical exam. There are other services that many clinics provide uniformly.
For example, whether it’s advisable or not, many clinics drug test all patients with the same frequency, regardless of time in treatment or past test results (though even with drug testing, there are circumstances where additional drug tests or retesting of a urine sample are required - so such services may be utilized more often for some patients than others).
Nonetheless, other services are not utilized uniformly - most notably, counseling and group therapy. The need for these services varies considerably from patient to patient and over the course of time. I am certainly no expert, but I suspect that counseling is the single biggest expense of maintenance treatment (given that most patients see the doctor no more than once a month after the initial dosage adjustments/stabilization period). What it boils down to is this: how can it be fair to charge a patient who sees a counselor twice a month and another patient who sees a counselor once a week the same amount?
Thus, it is extremely unfair that I am essentially forced to pay for services not rendered. I receive twice a month counseling rather than once a week counseling, yet I do not get any discount for the weeks that I do not counsel. This is why charges should be by service rather than one flat rate... so that on those weeks where I do not see a counselor I am charged a smaller total amount than the weeks when I do see a counselor.
In truth, I would not mind so much if the savings [from me not utilizing
the counseling that I am paying for] were used to help patients in need
(i.e.: to provide more frequent counseling to patients who need it or to
provide discounts for patients having difficulties affording treatment),
but I know that the savings are going into the clinic’s pocketbook [profit
margin]. This may not be true of all clinics, but it is probably
the case most of the time at most [for-profit] clinics that charge a flat
rate for treatment.
Thus, I am paying what seems like a large amount of money for not that
many services. Methadone Today has mentioned the fact
that the medication itself is quite inexpensive, so that doesn’t explain
the cost. I realize that clinics must pay their staff, but I don’t
believe that the ten minutes a week the dosing nurse spends on me costs
that much - so that doesn’t explain the cost either. I welcome clinic
owners or staff to explain to me just what I am paying this large amount
of money for.
With just about any other treatment, bills are itemized by services rendered. Look at your doctor bills, and you may see a charge for “X-rays”, taking blood and laboratory work, etc. Even dentist bills for routine exams are typically itemized - and the patient is not charged the same amount of money when X-rays aren’t taken. Laws should be reformed to require charges based on services rendered rather than one flat rate.
Editor’s Note: The author certainly has a point about the need to charge fees for services rendered rather than a flat rate. However, we still believe that the main issue is the high cost of methadone/ opiate agonist treatment in general. As long as state and federal regulations limit competition with excessive requirements, clinic monopolies [or virtual monopolies] will exist. Without serious competition, methadone clinics are free to charge exorbitant fees.
To see what we are talking about, one only needs to go to a state where few clinics operate or where neighboring states don’t have methadone treatment - it’s no coincidence that the cost of treatment is higher in such states. Clinics in Detroit, Michigan do not charge as much as clinics in certain states [where treatment costs $100 or more per week] because there is relatively more competition in Detroit - not because clinic counselors get paid less in Detroit or due to any legitimate cost factor.
Besides increased competition, the real remedy for the lack of access to treatment [due to cost] is better insurance coverage. As discussed on page 4, insurance companies often don’t cover methadone treatment - if they provide decent coverage for substance abuse treatment at all. What’s needed is federal legislation requiring insurance companies to cover substance abuse treatment-- including methadone maintenance--to the same extent they cover other medical treatments. In addition, health insurance companies should not be able to arbitrarily decide which substance abuse treatment modalities they will and will not cover (either explicitly or by not having any methadone clinics “in-network” [in the case of PPOs or HMOs]).
On a related note, we are concerned that clinics will be reluctant to
provide 14- or 30-day supplies of take-home medication to eligible patients
out of fear that patients receiving such take-home supplies will expect
a reduction in treatment cost. Without increased competition or office-based
treatment, the benefits of a more liberal take-home schedule may never
be realized.
Please understand that Methadone Today is solely supported by subscriptions and donations--we do not receive monies from any federal, state, or local government or municipality or private grants. Furthermore, Methadone Today is run entirely by volunteers; no one receives a wage or salary, so any donations or subscription fees are used to print and distribute newsletters.
To those readers who obtain copies of Methadone Today from their clinics--please realize that subscribers are in effect paying for the newsletters you obtain, as most clinics do not pay a subscription fee for the newsletters we provide. If you have been picking up Methadone Today from your clinic, please consider purchasing a subscription; by doing so, you will allow us to continue to print Methadone Today, which educates patients as well as clinic staff and advocates for patients’ rights. Subscribing also benefits you, as each issue will be mailed directly to you at the beginning of the month, and you don’t have to worry about your clinic running out.
To present subscribers: we sincerely apologize that we cannot print as many issues as previously stated. If you would like an adjustment to your subscription (issues added on), please contact us at the address below--to receive such an adjustment, you must contact us by September 30, 2000. If you do not ask for this adjustment, we will be able to continue publishing just that much longer. We are truly sorry that our faithful subscribers must bear the burden for those who continue to read the newsletter but feel they have no responsibility to pay for it.
We have been making personalized, laminated Medical Alert cards for methadone patients to carry in their wallets. On one side of the card, it contains your name, your clinic's name, and your clinic's phone number. On the other side, there is a list of antagonists that should not be given to you as a methadone patient. It also warns that use of these medications will cause a syndrome that will necessitate immediate hospitalization. The card will help you in case you are unable to tell medical personnel what medications are contraindicated while you are taking methadone.
For a personalized, laminated methadone MEDICAL ALERT card, send your name, clinic's name, clinic's phone number,& self-addressed, stamped envelope [SASE] - cannot be processed without preceding - $3 with any order (subscription to Methadone Today or DONT membership), $5 without order.
Name Phone:
Address Fax:
City/State/Zip
E-mail Address
Clinic Phone
Note: Do a Print Preview (usually from the File Menu on your browser), and you can find out what page you should print so that you can just print this form and not the whole file.
Methadone patient advocates regularly stress the need to educate the general public about the benefits of methadone treatment. As a methadone patient, I have seen where the negative attitudes about the treatment are sown: at methadone clinics by certain doctors and counselors.
I recently saw a clinic doctor for a 60-day examination. He asked how long I had been at the clinic and when I responded, he remarked that this was “too long.” I find it interesting that without knowing me or even reading my patient file, he can know how long in maintenance treatment is “too long.” This is not the first time I’ve had a clinic doctor make such a comment--only a week or two after starting treatment, I had a doctor try to bully me into starting to withdraw from my medication, and when I wouldn’t agree to it, he said that I was doing it anyway. The following day, I had to actually go to my counselor, who got me in to see another doctor who would abort the withdrawal.
I’ve also had counselors pressure me to withdraw (I soon learned that counselors do not have any real power in ordering dosage changes/withdrawal - they can inform the doctor of their opinion or try to persuade you to do something, but that’s about it). This bothers me in part, because I do not agree with counselors pressuring patients to do anything. In my opinion, a counselor should be the one who tells you what your options are and helps you achieve your goals (YOUR goals, not their goals); they should not be telling you what to do or pressuring you to do something (i.e.: withdrawal from medication). Counselors should certainly not be pressuring you to do something without informing you of the potential risks. For example, there is a very high relapse rate [80-90%] associated with withdrawal.
But this is about more than what the role of the doctor or counselor
should be. The actions of the doctors and counselors discussed above
convey the message that maintenance treatment is a negative. How
can we ever hope to convince people that methadone maintenance is a legitimate
treatment when many doctors and counselors in the field [the supposed
experts] perpetuate the very negative attitudes we are attempting
to combat? We can only hope that the proposed accreditation-based
federal regulations will require doctors and counselors to take a course
or attend a seminar that properly educates them about maintenance treatment.
The college or medical school courses counselors and doctors take do not
cover maintenance treatment.
This is not to say that most or even the majority of clinic doctors
and counselors are guilty of this. In fact, clinic staff have a role
to play in changing the attitudes and behavior of their colleagues who
perpetuate such negative attitudes about methadone maintenance.
A recent study* looked at the cost effectiveness of methadone maintenance treatment and other related issues. Among the author’s contentions is that the lack of health insurance coverage and government subsidizing of maintenance treatment is the result of morality judgements more than anything else.
The author then suggested that cost-effectiveness may be the driving
force in increasing coverage of maintenance treatment.
Certainly the author’s prediction has some merit to it.
Americans do seem to have a puritan slant to their politics and philosophies.
However, most Americans are not extremely hard line in such attitudes when
posed with a pragmatic solution--especially when it has a positive impact
on their pocketbook.
Then again, perhaps the biggest question is not whether the American people will be convinced by cost-effectiveness arguments but whether health insurance companies will be--or whether politicians will be, as it is up to them to pass legislation that requires insurance companies to cover substance abuse treatment to the same extent they cover other categories of medical treatment. Note that of the two substance abuse treatment parity bills introduced in Congress last session--neither of which passed--one of them would not cover maintenance treatment.
*”The Cost-Effectiveness of Methadone Maintenance,” Paul G. Barnett,
Ph.D., and Sally S. Hui, B.A. The Mount Sinai Journal of Medicine:
Vol 67, No. 5 & 6 (October & November 2000).
Certain doctors in the methadone treatment field have expressed reservations about medical maintenance treatment or even providing relatively larger take-home supplies generally whether in the context of traditional clinics or medical maintenance (doctor’s offices). They apparently are either unaware of or choose to ignore the fact that medical maintenance treatment has been practiced for years as a pilot study without the serious problems they envision.
Specifically, many of the concerned doctors believe that patients at some point will take extra doses early and wind up running out of medication before they are due for a refill/office visit. Aside from the possibility of overdose, the worry is that upon running out of medication, the patient will use illicit opiates, other drugs or alcohol to tide them over until they are to receive their next take-home supply. Besides being contradicted by the medical maintenance pilot studies, the US experience with shorter take-home supplies largely puts these concerns to rest. The actual amount of take-home doses being provided plays a smaller role in medication misuse (e.g.: not taking the medication as prescribed) than does an underdosed patient. Put simply, if a patient is properly dosed and can handle a 6-day supply of take-homes, it is reasonable to believe that he/she can handle a 14- or 30-day take-home supply.
These doctors have such an initial reaction to 30-day take-home supplies because they are so accustomed to providing small take-home supplies. They simply cannot fathom giving what they see as a huge supply of medication to “drug addicted” individuals of whom they still have a stereotypical view. They assume that as drug addicts they simply would not have the “discipline” to hold on to a relatively large supply of medication without “dipping into it” prematurely. At least as it’s envisioned now, medical maintenance would only be available to stable patients who’ve been in treatment over two years; there is no reason to believe that such patients would misuse their take-home medication.
*”Methadone Medical Maintenance (MMM): Treating Chronic Opioid Dependence in Private Medical Practice - A Summary Report (1983-1998),” Edwin A. Salsitz, M.D., Herman Joseph, Ph.D., et. al. The Mount Sinai Journal of Medicine: Vol. 67, No. 5 & 6 (October & November 2000).
At this website, you can get information about methadone treatment in other countries. Designed for those traveling outside of their own country, this website gives detailed information including whether it’s legal to bring a supply of methadone into a country and, if so, what documentation is required; whether a visitor can get medicated in a country and, if so, how to make arrangements to do so; where a visitor would go to be medicated, etc. In addition, this website provides basic information regarding methadone treatment regulations and data (i.e., what are the eligibility requirements for getting into treatment, how many are presently receiving treatment in a given country, etc.)
This site is highly recommended to anyone considering traveling outside of the US [or the country in which you currently reside]. As many countries require arrangements well in advance in order to “guest dose” there, this site is excellent for planning a trip ahead of time.
