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What Do These New Federal Regulations Mean to MMT Patients? -
CT Senate Bill: Treatment for Inmates - Aaron Rolnick
Doctor Spreads Misinformation -
Naltrexone Dangers
LAAM
Warning - Update
Advocates for Recovery through Medicine (ARM) has printed a two page document briefly explaining the new federal regulations. In the March issue of Methadone Today, we did detail a few of the more important aspects of the federal regulations, however, ARM’s publication covers a wider range of subjects and provides concise answers. For this reason and because it is vital that patients are educated as to what the federal regulations do and do not require (individual states may have more stringent regulations), we are printing portions of the ARM document below.
What is the major change that will affect patients?
A major change is the new takehome schedules. Patients must be “in compliance”.
First Quarter in Treatment - patients eligible for one takehome
a week
Second Quarter - two takehomes per week
Third Quarter - three takehomes per week
Fourth Quarter - six takehomes per week, i.e. once a week pickup
Second Year in Treatment - 14-day takehomes/twice a month pickup
Third Year in Treatment - 31-day takehomes/once a month pickup
Patients taking LAAM will now have the same takehome schedule
Do the new regulations allow programs to dispense pills?
Yes, the restriction to dispense only liquid medications has been eliminated. Patients will be allowed to have medication in solid (pill) form. So patients with 31-day takehomes should receive just one bottle of pills per month.
Do the “feds” still have to be notified if patients on doses higher than 100 mg get takehomes?
No, this reporting requirement has been eliminated. Any patient with a dose over 100 mg can have takehomes; all it takes now is a notation in the patient’s chart. If you are restricting your dose to under 100 mg in order to keep your takehomes, this is no longer necessary. Go to your program and get your dose raised if you need to.
Do the regs make any provisions for patient grievances?
The SAMHSA/CSAT Accreditation Guidelines, as well as the accreditation standards developed from them, include provisions for accepting and acting upon patient grievances. For the first time, patients will have access to a formal grievance procedure, through CARF (ph: 520-325-1044) and JCAHO (ph: 800-994-6610), the accrediting agencies, and through CSAT, which will soon be implementing an 800 Helpline number for patients.
Do the new regs allow any doctor to prescribe methadone to treat opiate addiction?
No. Current regulations enforced by the DEA do not permit DEA registered doctors to prescribe narcotic drugs, including methadone and LAAM, for the treatment of opiate addiction. But any doctor with a narcotics license can prescribe methadone for pain. This has not changed. See below for steps to take to have your doctor prescribe for addiction.
If your private physician (we do not have lists of physicians) is interested in becoming an Office Based Opioid Treatment (OBOT) provider and treating your opiate addiction, there are resources available. Contact ARM on the Internet at www.arm-advocates.org or your local ARM chapter. If you do not have Internet access, write to the address at the bottom of page 4 of this issue of Methadone Today or call ARM at (615) 354-1320.
Also, Robert Lubran at CSAT can assist physicians who want to become OBOT providers. Mr. Lubran can be reached at 301-443-7745 or [by e-mail at] rlubran@samhsa.gov. CSAT is interested in assisting physicians with OBOT.
The Connecticut State Senate is considering a bill that would make substance abuse treatment available to drug addicted inmates, including methadone maintenance treatment. This is big news as, to our knowledge, no state has legislation making methadone maintenance available to inmates, nor are we aware of any other state legislature even considering passage of this kind of legislation.
As Methadone Today has reported in the past, maintenance treatment in U.S. prisons is nearly unheard of. City or county jails tend to vary in their policies--many will permit pregnant inmates who were on maintenance treatment prior to incarceration to continue maintenance treatment, and a few will allow any inmate to continue maintenance treatment. Jails that will not maintain inmates will sometimes permit tapers [withdrawal] of varying lengths (usually it will be a 5 or 6 day withdrawal, but we were told of one jail that provided a 30 day withdrawal); at the least, they may provide non-opiate medications to ease withdrawal symptoms.
There are states with laws requiring some sort of withdrawal regimen for inmates who were on methadone maintenance treatment prior to incarceration, but the laws we are aware of only require a 6-day withdrawal, at best (better than nothing, but not what we would consider a humane treatment). Opiate addicts not on maintenance treatment prior to incarceration (i.e., those who were actively using illicit opiates) are usually out-of-luck. Laws requiring some sort of withdrawal regimen often only apply to individuals already on maintenance treatment and few jails are sympathetic to [current] illicit opiate addicts, with a possible exception for pregnant opiate addicts.
The Connecticut bill is not perfect but represents a step in the right direction. In Section 1, it states: “Inmates incarcerated for a period likely to exceed one year are not eligible for maintenance treatment pursuant to this section.” The reason for this restriction is unclear--once prisons start maintaining inmates, it would not be much of an additional cost or burden to also provide maintenance to inmates to be incarcerated for over a year. However, the benefit to these inmates and society of providing maintenance treatment would be substantial. Most of these inmates will be released at some point and it is well-established that maintenance treatment dramatically reduces criminal activity among patients.
Still, if this bill becomes law, it will make maintenance treatment available to a large number of inmates in the state and will hopefully change the view of maintenance treatment by politicians and correction officials. Prisons are increasingly under fire for doing little, if anything, to rehabilitate inmates. Many would argue that prison actually produces hardened criminals. If making maintenance treatment available to inmates actually lowers recidivism rates (i.e.,: after being released, fewer resume criminal activity), other states will be forced to at least consider passing legislation requiring prisons to provide maintenance treatment to opiate addicted inmates.
It makes no sense to prevent opiate addicted inmates access to the most effective treatment for opiate addiction. Many of these individuals were convicted of crimes somehow linked or related to their opiate addiction--whether the actual purchase or possession of illicit drugs, sale of illicit drugs, or some other crime to support their habit. If they can be successfully treated for opiate addiction, they will be far less likely to commit crimes once they are released from prison [see the quotes below this article for more information]. So, even if legislators have no regard for the welfare of inmates, they should understand that providing maintenance treatment to inmates will benefit everyone, both monetarily--as it costs money to prosecute and imprison people, besides the actual losses incurred by theft--and as a result of having a safer society).
Unfortunately, it appears that the proposed Connecticut bill does not make maintenance treatment available to pretrial detainees. Individuals being held in jail awaiting trial have not been convicted of a crime yet, so presumably they deserve to be treated at least as well as incarcerated convicts, and therefore should have the same access to maintenance treatment. Perhaps the greatest injustice is that most jails will not maintain pretrial detainees who were on opiate maintenance treatment prior to incarceration.
Editor’s Note: The following are quotes from Partnership for Recovery’s “Fairness in Recovery Fact Sheet.”
Untreated addiction costs America $400 billion per year (Source: Substance Abuse: The Nation’s Number one Health Problem, Brandeis University, Schneider Institute for Health Policy, 2001)
Treatment of addiction is as successful as other chronic diseases--diabetes, hypertension and asthma (Source: National Institute on Drug Abuse (NIDA), Principles of Drug Addiction Treatment, 1999)
One year of methadone treatment costs $4700 per patient--one year of imprisonment is $18,400. (Source: National Institute on Drug Abuse, Principles of Drug Addiction Treatment, 1999)
For every $1 spent on treatment yields a return of up to $7 in a reduction of drug related crime and criminal justice costs. (Source: National Institute on Drug Abuse, Principles of Drug Addiction Treatment, 1999)
In the case of substance abuse treatment in prisons and jails, all these facts add up to this: substance abuse treatment, including methadone maintenance, is needed in U.S. correctional institutions and would benefit drug addicted inmates, as well as society as a whole. The U.S. incarcerates a larger portion of their population than any other country in the world, and they need to look at ways to prevent released convicts from returning to prison.
Providing substance abuse treatment in jails and prisons will reduce the financial burden on U.S. citizens--starting with the tremendous cost of keeping people in such institutions. But it goes further than that, as drug addicts in treatment are far more likely to be productive members of society and pay taxes, far less likely to commit crimes and cause financial hardship to others in the form of stolen property and higher insurance premiums, etc.
Most inmates will be released at some point. Absent treatment,
an incarcerated drug addict is likely to return to criminal activity when
released. The state has a responsibility to both society and incarcerated
addicts themselves to properly treat these inmates. Hopefully, Connecticut
will pass this bill, making substance abuse treatment available to inmates,
and other states will follow suit.
Although I agree with many things the author said, especially his references to the demeaning treatment expected at many methadone clinics, I resent his "better than the junkie off the street" attitude. After all, where did he come from? And isn't twenty years a rather long program? Although it's difficult to find a good counselor, I really feel he should make an effort to do so. Maybe he would learn that we're all basically alike, we all have the same chemical in our brain that makes us addicts. No one is "better than".
Although I commend his 20 years of sobriety, I caution that it is exactly that "better than" attitude that causes relapse; an addict is never "safe". -JJ (Shelby Township, Michigan)
Dear JJ,
We appreciate you taking the time to write us with your comments and urge the rest of our readers to write in with articles, letters, or comments regarding past issues of Methadone Today.
We share your agreement with and criticism of this article. In fact, we felt that the treatment the author described is demeaning and inappropriate for ALL patients whether they started treatment yesterday or have been free of illicit drugs for 20 years. (By the way, why would you use a critical tone because this patient has taken this medication for 20 years? Some patients will take it for life. Would you comment about a diabetic taking insulin for 20 years?)
On the other hand, stable patients generally require less services
and do not need to be drug tested--at least as much as a new patient or
a patient who continues to use illicit drugs. We should add that
a patient does not need to be in treatment and abstinent from illicit drugs
for 20 years to be defined as stable. The federal government apparently
agrees, as patients may be eligible for 30-day take-home supplies after
two years--and 14-day take-home supplies after one year.
====================
I drove myself to the hospital in the middle of the night with severe stomach cramps, I thought it was all over. I told them I was on methadone, because I was afraid that they would give me something that would reverse it. They told me I passed two kidney stones while I was there. Once they knew I was on methadone, all they would give me was Motrin, even though the pain was very bad. Then, as soon as the kidney stones came out, they sent me home.
You would think by now I should know better than to open my mouth
and tell anybody about it [methadone maintenance]!
-G from Cleveland
Dear G,
We are sorry to hear of your bad experience. Kidney stones are extremely painful, and you should have been given something stronger than Motrin. Neither of the editors have had kidney stones, but just from talking to those that have, it is clear that opiate medications are necessary for adequate pain relief.
Too many doctors are still in the dark on the issue of maintenance treatment and pain relief. A methadone maintenance patient receives no pain relief from his/her maintenance dose of methadone. This is due to tolerance. A methadone maintenance patient develops tolerance to the analgesic effects of the methadone dose. Therefore, a maintenance patient, like anyone else, requires additional medication to relieve pain. Depending upon the severity of pain, such medication may include opiates. In fact, methadone maintenance patients require greater doses of opiates more frequently than their opiate naive counterparts to achieve equivalent pain relief. Thus, contrary to the belief of some physicians, methadone maintenance patients require the same or greater amounts of pain medication for the relief of pain.
We suggest that you take a Dear Doctor letter* with you whenever you think you will need pain medication. Have it handy in case of just such an emergency; otherwise, do not tell them that you are taking methadone.
However, you do have a legitimate concern about informing them because of the off-chance that they might give you a narcotic antagonist. As bad as being under medicated for pain is, being given a narcotic antagonist is probably worse. A past issue of Methadone Today had an account of an experience where a patient was given a narcotic antagonist because the patient did not inform hospital staff that she was taking methadone. To put it mildly, she had severe withdrawal symptoms.
We suggest that you complain to the hospital. Recent government regulations have mandated the adequate management of pain, so the hospital could get in trouble for not controlling your pain adequately.
Dr. Ira Chasnoff, a pediatrician, gave a seminar which included
comments about methadone maintenance treatment and pregnancy, as well as
breast feeding. The recommendations he gave run counter to research
as well as the opinion of experts in the medical field.
We advise medical professionals like Dr. Chasnoff to do some research and fact-checking before making recommendations regarding substance abuse treatment. At one time, physicians were advised to only prescribe [relatively] low doses of methadone to pregnant opiate addicts; however, it was soon discovered that methadone maintenance treatment--even at higher doses--did not cause injury or long-term problems to the fetus, during pregnancy or after birth. On the other hand, under dosing pregnant patients presents needless stress and discomfort to the mother--and potentially to the fetus, and seriously increases the risk of relapse to illicit opiate use (which would be dangerous to the fetus and mother).
The recommendations of medical experts have been published in various publications and handbooks. As a matter of fact, the statements made in the previous paragraph are supported by such publications, including the TIP/TAP manuals (published by CSAT [Center for Substance Abuse Treatment], the government agency which is handling the enforcement of the new federal regulations) and the recently released “About Methadone” handbooks (published by the Lindesmith Center-Drug Policy Foundation, with collaborators including Dr. J. Thomas Payte--a highly respected methadone maintenance treatment practitioner). The opinions and recommendations expressed in such publications represents the consensus viewpoints of experts in this area of medicine. Thus, if Dr. Chasnoff had not kept track of research in this area, he could have easily read these publications (the TIP/TAP manuals are free government publications) or consulted with specialists.
Clearly, physicians such as Dr. Chasnoff, spreading misinformation
about maintenance treatment keeps the myths and stigma against the treatment
going, but it also endangers patients--patients of physicians taking his
advice risk serious harm or death to them and their fetus[es].