A Stable Methadone Patient Speaks Out - Name withheld by request

New Federal Regulations:  Real Change? -

Dear Methadone Today-

Trial of UROD Provider Underway -

Religious Organizations May Get Funds for Treatment -

Doctor's Column -

    Do Not Take St. John's Wort While on Prescribed Medications - Dr. Marc Shinderman
 
 

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 My addiction story started in the early 1970s.  I have been on methadone all of my adult life, and I never want to be without it.  I am no different than an insulin-dependent person or one who takes blood pressure medication.  However, I am treated very differently from those  who take prescription medications other than methadone--I am treated like a fool.

 I am forced to go to a place where there are addicts who range from early addiction, to those who use illicit drugs occasionally, to those like myself who have not used any illicit drugs for 15-20 or even up to 30 years.  Those of us who have not used illicit drugs for many years feel embarrassed to have to go to the methadone clinic, but we have no choices as of yet.  We must go to a methadone clinic or face withdrawal from heroin [or other short-acting opiates], the drug(s) we fear more than anything.

 Though we are matured in age and far removed from the drug games, the methadone clinic staff still reduce us to the level of a full heroin user.  We are still asked to go into the bathroom with a nurse who watches us pee so the urine can be checked for drug use.  There are many of us who do not use heroin any more and will never use again.  We have not had a positive opiate urine for 20 years.

 [Besides the issue that drug tests are intrusive and unnecessary for us], another problem [related to drug testing] is with the other drugs that our doctors often place us on--such as benzodiazepines (i.e., Valium).  The fact of the matter is that there are many of us with anxieties that are at times unmanageable.  My doctor has prescribed Xanax [a benzodiazepine] to me; I need a drug like this to reduce the anxiety attacks (panic attacks) that I get occasionally.  Because of this drug I am now able to mingle with everyone in the world without fear.

  I get a panic attack about once or twice a week.  They are never serious, and Xanax devolves the condition very fast.  I use this medication so infrequently that 30 tablets last me four or five months.  The problem I am running into is that the methadone clinic will not allow this drug or any other benzodiazepine on their program.  Because of the occasional need for this medication, I get a positive urine result that causes the program to rescind my take-home allowances.  That means I have to come in every day.  I have asked them to hold my Xanax at the nurses’ station and give me one a week [that is all I take], but they won’t agree to that.  It seems like as soon as I get back two take-home days of methadone, a urine test will come back positive for benzodiazepines.  I get so frustrated at times that I just don't know what to do.

 I do understand the seriousness of benzodiazepines and the magnitude of its abuse.  I also understand just how wonderful Xanax has been in getting me back into the world.  I was going to be a house potato.  I was too panicky to go anywhere.  As I stated above, these panic attacks don't happen every day.  I don't know why they occur; I just know that they stop me in my tracks.  Is there ever going to be any change to the idea that no one can take anti-anxiety drugs while on methadone?

 Patients like myself are asking for some dignity.  I would love to go to a doctor and get a prescription for methadone, just as I do to get my hormone pills.  I am ultimately in charge of my body.  I am not a child, and I need my time to go to school and work, not to drive 20 miles a day to wait in line for half an hour, plus submit to supervised urine testing two or three times a week.  It’s time for change.

Editor’s Note: We agree with the author’s belief that he should not have to be subject to such rigid conditions after being in treatment and stable for such a long period of time.  In fact, we do not think that a patient should have to be in treatment for 10-20 years before being treated as a patient rather than as a child or a criminal.

 The federal government has also indicated that these sort of rules are more rigid than necessary.  The new federal regulations will allow up to 30-day take-home supplies for stable patients who have been in treatment for two years or more.  Thus, even the federal government has finally acknowledged that rigid rules and supervision is not necessary for stable patients.

 We also agree that supervised urine testing is not necessary under normal circumstances--it is intrusive, humiliating, and unnecessary given the other methods available to detect falsification (i.e., temperature and PH tests).

 Dr. Marc Shinderman of our Medical Advisory Board has stated that a “blanket prohibition” on benzodiazepines for methadone/opiate maintenance patients is not a good idea.  Benzodiazepines do have a potential for abuse, especially when it comes to opiate addicts--this should certainly be taken into account--but Dr. Shinderman believes that there are a small minority of methadone patients who require benzodiazepines for the treatment of certain anxiety disorders.  Benzodiazepines are also occasionally prescribed on a short-term basis to treat massive anxiety, insomnia, etc. caused by a traumatic event, such as death of a loved one.  Many methadone clinics, such as the author’s, prohibit the prescribed use of benzodiazepines on a short-term or long-term basis.

 But we have a bigger issue with the use of such blanket prohibitions on prescribed medications in general.  Physicians are legally permitted to prescribe medications because they have the education and expertise to diagnose and treat patients for medical/psychiatric conditions.  What gives methadone clinics the right to “prohibit” a medication that has been prescribed by a physician--a physician that may very well have more expertise in treating the condition for which the medication was prescribed than the methadone clinic physician?  Though this may be legal for methadone clinics to do, we certainly consider it unethical.
 
 

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 An unfortunate peculiarity of the new take-home provisions, which will impact patients in every state, is that after 90 days in treatment and stable (illicit drug-free, etc.), patients would actually be eligible for less take-homes than under the previous regulations; patients would only be eligible to receive three take-home doses per week (e.g., they must attend their clinic four days per week), as opposed to the four take-home doses per week previously permitted.  Basically, the difference is that now, patients will have to continue to attend their clinic on Saturday.  Otherwise, the take-home provisions under the new regulations are more favorable... however, in states with take-home regulations that mimic the prior federal take-home provisions, patients will see little real change in methadone take-home practices [and this change would be decidedly for the worse].

 At minimum, most states are very likely to allow LAAM take-homes, which were prohibited by the prior federal regulations even for travel or under “hardship” circumstances, but are permitted under the new regulations.  The take-home provisions are the same for LAAM as for methadone.  Only a small minority of maintenance patients are on LAAM, but this is a major benefit to these individuals.  LAAM patients have complained about having to switch to methadone when traveling unless there is a clinic that dispenses LAAM where they are traveling to and the patient is willing and able to take the time to go to this clinic and dose.  Furthermore, many clinics are closed Sundays, resulting in a dosing schedule that some LAAM patients have difficulty with.  Dr. Marc Shinderman and Dr. Andrew Byrne noted in a past Doctor Column that some LAAM patients would be better off on an every other day dosing schedule (e.g., Monday-Wednesday-Friday-Sunday-Tuesday-Thursday-Saturday, and so on).  The new regulations will enable such a dosing schedule.  Thus, LAAM patients in most states will see a real benefit from this regulatory change.

 One major change to the federal regulations that will affect treatment in all states is that all treatment providers will have to be accredited.  In Michigan, treatment providers can only accept Medicaid patients if they are accredited, so providers in Michigan have already been accredited in virtually all cases--thus, this may not represent a major change here.  In most other states, however, accreditation of treatment providers has not been standard practice.  It remains to be seen how this will actually impact patients, if at all.  Note that the new federal regulations do not require treatment providers to be licensed by the FDA or any other agency, as was the case under the prior regulations, though states may have their own licensing requirements.

 Office-based or “medical maintenance” treatment is another major issue concerning the potential impact of the new regulations on patients.  The prior federal regulations did not prohibit treatment in an office-based setting (provided by a physician’s private practice in a doctor’s office); however, the rigid requirements made providing treatment in such a context virtually impossible.

 There are other areas where the new regulations vary from the prior ones.  For instance, the new regulations do not require a clinic doctor to take any special measures when providing a dose greater than 100 mg., whereas the prior regulations required the doctor to “justify” any daily dose over 100 mg. in the patient’s records, and take-homes were prohibited “unless the [treatment] program has received prior approval from the Food and Drug Administration [FDA] with the concurrence of the State [methadone] authority [SMA].”  The poor wording of this provision created great confusion among treatment providers as well as patients.  These rules had the effect of discouraging clinic physicians from providing doses over 100 mg.  By omitting these rules, the new regulations should improve the quality of treatment, as evidence indicates that a large number of methadone patients need doses in excess of 100 mg.

 Some states do not allow patients with doses above a certain level to obtain take-homes, and a few states have a maximum allowable dosage (e.g.,  patients cannot get a daily dose greater than the state mandated “dose cap”).  Thus, even the federal changes will not have a significant effect on some patients, depending on what state they are in.  However, we do believe that states with such dosing regulations are the minority, and these states will be under increasing pressure to drop these unreasonable provisions.
 
 

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Dear Methadone Today,

 I shall ever be grateful to you for encouraging me to insist on an adequate dosage.  At present, after one year in my program, I have two take homes a week, and my dosage is 120 mg/day (higher than almost everyone at the clinic).

 By the way, I would recommend my program to anyone.  My counselor is friendly, easy to talk to, and seems to have a lot of natural empathy.  I do think that there ought to be a patient advocate sitting in on the weekly clinic staff meetings and have suggested it.  I wonder if many clinics have a patient representative.  -Ken, California

Dear Ken,

 You make an excellent point.  American society has adhered to puritanical beliefs.  Perhaps this is why the perceived link between [im]morality and drug addiction is so difficult to overcome and has even been internalized by drug addicted individuals who know that drug addiction really is a disease--not a moral weakness.  But we shouldn’t get discouraged--change through education takes time.

 We are not aware of many clinics which have a “patient representative”, but we would definitely like to see such an individual at all clinics.  Patients deserve a voice.  We are also hoping that accreditation, which is mandated under the new federal regulations, will bring more patient input into opiate maintenance treatment.

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 As reporter Iver Peterson explains in “Malpractice Case Begins for Specialist in Addiction Who Used a Cold-Turkey Method”, Dr. Gooberman is not being tried for a crime; rather, the trial will determine whether Dr. Gooberman will lose his medical license (obviously, if he lost his license, it would be illegal for him to perform UROD--or any other medical treatment or procedure).  Peterson states that, “the two of them [Dr. Gooberman and a staff member] have been charged with using unproven medical treatments, administering general anesthesia without proper supervision and discharging their patients without providing for adequate after-care.”

 According to this article, the State of New Jersey asserts that at minimum, Dr. Gooberman’s UROD treatments are responsible for seven deaths.  At issue is not only the UROD procedure, “[but] the outpatient nature of Dr. Gooberman’s practice.”  He allegedly would routinely release UROD patients into the care of a friend or relative with no training or medical background very shortly after the procedure, when they should have been monitored by professionals in an inpatient setting.

 Yet, according to the aforementioned article, Dr. Gooberman denies any wrongdoing and has apparently prepared a vigorous defense.  He blames some of the deaths on the use of “non-opiate drugs, such as cocaine, immediately after the treatment” and also blames some of the deaths on undetectable “medical problems.”  (It should be noted that UROD has been associated with deaths outside of Dr. Gooberman’s practice.)

 We at Methadone Today question the safety and efficacy of UROD.  From patient accounts, we also gather that UROD is not a humane procedure.  But what we dislike the most about UROD is that many providers of UROD, particularly Dr. Gooberman, are dishonest with prospective patients about the treatment.  Most of the UROD stories we receive indicate that UROD providers deliberately misrepresented various aspects of the treatment so that the prospective patient would agree to undergo the procedure.  For instance, most UROD providers claim that once the procedure is over and the patient has awoke that any remaining withdrawal symptoms are fairly mild, yet in nearly every UROD story we received, the patient  was in severe withdrawal following the procedure.  Many of the individuals who sent us their stories felt that they had been tricked into undergoing the procedure--spending a large sum of money for a treatment that turned out to be inferior to conventional withdrawal.   As for Dr. Gooberman, we were appalled at his shameless hawking of UROD on television programs like “Montel” and the poor treatment of patients in his care.  Perhaps this will be the end of his UROD practice.

*“Malpractice Case Begins for Specialist in Addiction Who Used a Cold-Turkey Method,” Iver Peterson Ercerville, January 4, 2001.
 
 

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 While we see nothing wrong per se with drug-addicted individuals seeking religion to assist with their problems, strengthening religious beliefs and practices--at least in itself--does not constitute treatment for drug addiction, a disease.  It would be a travesty if federal money were diverted away from proven effective treatment modalities, such as methadone maintenance treatment, which remains inaccessible to the majority of opiate addicted individuals.

 We urge President Bush and other politicians to back up their statements about drug addiction being a “disease” and the need to focus more on drug treatment with real action rather than political posturing.  A good start would be for the federal government to pass a substance abuse treatment parity bill.  If drug addiction is a disease, just like diabetes and hypertension, then there is no justification for health insurance companies to provide less coverage for substance abuse treatment than for other medical treatments.  As the title indicates, a substance abuse parity bill would require health insurance companies to provide the same or equivalent coverage for substance abuse treatment as for other treatments.  Such a bill has been introduced in the U.S. Congress this year and awaits consideration:  “The Mental Health and Substance Abuse Parity Act.”
 
 

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