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CSAT Holds Technical Assistance Workshop - by Chris Kelly, Director
Media Reports on Addiction to Painkillers - by Aaron Rolnick
Note to Advocates: Grant Opportunity
To Michigan Methadone Patients - Beth
Research into Buprenorphine-Naloxone Combo Raise Questions of Safety, Ethics - July 2001, Vol VI, No. VII
The new Federal Opioid Treatment Program regulations took effect on May 18, 2001. These rules emphasize improving the quality of care, such as individualized treatment planning, increased medical supervision, and assessment of patient outcomes. Opioid Treatment Programs (OTPs) will have to be certified by SAMHSA in accordance with the standards described in the new regulations, including the new requirement that OTPs be accredited.
In order to assist in this huge change, CSAT is conducting a series of one-day regional Technical Assistance workshops to provide OTPs with information about the new regulatory requirements. CSAT is encouraging every OTP to send at least one representative to the workshop, and they also encourage patients and patient advocates to attend.
ARM-DC and ARM-VA representatives attended the first session, held on May 18, in Baltimore, MD. There were over 500 people in attendance. Dr. Westley Clark, director of CSAT spoke first. He again reiterated that dose caps of any kind, either written or implied, are no longer acceptable. Robert Lubran, director of OPAT, gave a brief presentation on the Final Rule. One of the major issues Mr. Lubran addressed was that of “diversion control.” CSAT intended the diversion control policy to address issues such as drug dealing around the OTPs, but in no way are any policies to make patient care more onerous or inaccessible. Mr. Lubran stated that “your community will determine your diversion control plan” and that the accrediting agencies will take a reasonable approach when examining such plans. Measures that restrict patient care are not encouraged, as blanket policies for every patient are just not necessary or required.
There was a “question and answer period”; very few questions were asked. For example, one provider asked that since HCV testing is not “required” under the new Federal Regulations, is it considered part of “adequate medical care” in light of the fact that, in some areas, up to 80% of MMT patients are infected with HCV? Mr. Lubran turned the question back on the provider – Is HCV testing considered “adequate medical care”? Duh. . . and this was the tone of the presentation. Most of the regulatory changes are not rocket science. All the provider really has to ask is, "Does this policy improve or impede patient care?” and go from there.
The third panel was a selection of five OTPs that had been through the “pilot accreditation” process. One OTP reported they had to hire a new full-time employee to create the paperwork necessary for accreditation; another OTP just used existing resources and did not spend an additional cent on accreditation. One OTP reported that they had to make their facility handicapped accessible in order to receive accreditation. All five reported that the process is very time and paperwork intensive. Unfortunately, we did not hear from the patients to see how they felt about the “pilot accreditation process”.
The following tentative schedule of TA workshops has been established:
June 12 Chicago, Illinois
June 19 Atlanta, Georgia
June 26 Los Angeles, California
June 29 Seattle, Washington
For additional information about the specific TA workshop or specific location you might be interested in attending – as well as for general technical assistance on the new regulations – CSAT has established a toll free Help Desk staffed with trained professionals who will be able to answer your questions. 866-INFO-OTP or E-mail: OTP@hq.row.com
It is very important that MMT patients attend these sessions if they can. This is an opportunity to ask key questions of CSAT, in front of an audience of providers. Questions like, “My program requires a serum level for doses above 120mgs, and the bpl costs $195.00. Is this a dose cap?” (True story – from a Texas program. In my opinion, this is an “economic” dose cap. Why should a patient’s dose be restricted because they cannot afford an inordinately expensive, and in most cases, unnecessary laboratory procedure?). Or “My program just bought and installed a whole set of expensive video cameras to watch patients give urine specimens. Is this allowed under the new Federal regulations? The CSAT Guidelines clearly state that “Programs collect all urine or other toxicological specimens in a therapeutic context that suggests trust and respect and minimizes falsification. Reliance on direct observation, video camera monitoring, or one-way mirrors, although necessary for some, is neither necessary nor appropriate for all patients.”
Here is our chance to make our voices heard. KNOWLEDGE IS POWER!
Note: By the time this issue becomes available to some of you, many of these workshops will have already been held. However, these questions are still valid. If your program has dose caps or blanket policies, please notify DONT-- (810) 658-9064, bethfrancisco@netzero.net, or PO Box 164, Davison, MI 48423-0164.
Obviously, the main issue is with the medication itself; counseling sessions can be rescheduled, but medication needs to be taken daily or every other day in the case of LAAM. All kinds of events can interfere with provision of treatment (i.e.: power outages, water or gas main breaks, floods, fires, tornadoes, earthquakes, hurricanes/typhoons, blizzards, etc.). Patients traveling greater distances to receive treatment are more likely to have problems with road closures as a result of a blizzard or road damage, but even patients who live within a walking distance of the facility will not be able to receive treatment if clinic staff cannot get to the clinic.
In areas with multiple clinics, providers may be able to work out a plan wherein one provider will provide medication to the patients of another provider if they are unable to dose patients at their facility. Using the same sort of logic, a treatment provider owning multiple facilities in an area are often prepared to send patients from one facility to another in the event that one or more of their facilities are not operational on a given day. In either case, such plans are a good idea for disaster preparedness.
Yet, these plans may be insufficient--particularly in areas prone to more widespread natural disasters. Different scenarios need to be considered, as well as whether the current plans are feasible and adequate for all probable disasters. For instance, the kind of plans discussed above are likely to be sufficient in the case of disruptions due to tornadoes; while tornadoes can cause severe damage, they are local phenomenon. It is highly unlikely that four clinics several miles apart will all suffer tornado damage at the same time. In contrast, a hurricane could conceivably put multiple facilities out of commission or make them inaccessible due to flooding or road damage. However, prior notice of a hurricane should be considered when making plans. A clinic could give patients an additional supply of take-home medication for the day[s] the hurricane is expected to hit).
Fortunately, Addiction Treatment Forum published an article in its Spring 1995 issue, “Clinic Disaster Preparedness--Are You Ready?” profiling the potential problems with planning for a disaster or other factors that may disrupt provision of services, and looking at how some clinics have dealt with such disruptions when they did occur.
Interviews ATF conducted and responses to an ATF reader survey suggest that one of the most common disaster plans was to have patients be dosed at another clinic in the area, as discussed above. However, a few problems with this approach were outlined in the article. First of all, providers often did not keep a duplicate copy of patient records off-site. One program director they interviewed related an incident where an overhead water pipe burst, causing serious flooding in the clinic. They were able to save the patient records and dispense methadone from another location; had some or all of the patient records been destroyed, they would have had major problems with dosing. Some of the problems discussed above would make the facility inaccessible--even if the patient records are not destroyed, they cannot be used if no one can get to them.
Second of all, ATF questioned whether an area clinic would have enough methadone stored to dose their own patients AND patients from another clinic; in an emergency situation, clinics would not have sufficient notice to stock up on extra methadone. As with the first concern [access to patient records], this should be addressed in advance; a clinic should figure out how much methadone they dispense in a day and find out whether the area clinic they are considering sending patients to would have enough extra methadone to dose their patients. If necessary, the clinic could plan to send half of their patients to one area clinic and the other half to another area clinic.
Third, ATF found that many of the clinics had not discussed or cleared their plans with regulatory agencies. Hopefully, the new federal regulations will partly address this concern; accreditors could review the treatment provider’s plans in case of a disaster during the accreditation process. But treatment providers should still talk to their State Methadone Authority (SMA) about any such plans.
Clearly, many methadone clinics are not as prepared for disasters
as they ought to be. Forty-one percent of respondents to ATF’s readers
survey answered that their clinic had no plan at all in place, and
certainly many more did not have sufficient plans. Clinics can and
should have a feasible disaster plan in place; the new federal regulations
give providers enough flexibility to continue treatment in a variety of
emergency situations.
The clinic immediately started to withdraw me 5 mg a day. The good news is that this only went on for two days. My parole officer was playing games, and I was released.
This is a big issue: methadone patients on parole or probation.
I was constantly harassed by my parole officer to get off of methadone.
She, of course, had no legal recourse because she couldn't override a doctor's
order. But that also didn't stop her from messing with me constantly.
This is why I spent six days in jail for traffic offenses; she had the
power to hold me as long as 21 working days for no reason.
She was so hell bent on getting me off methadone that she eventually
had my parole revoked on pure lies. I got wind of them looking for
me, so I had to jump off of methadone cold turkey. My thoughts, as
unclear as they were at that time (for fear of going back to jail), told
me it was easier to withdraw on the streets than in jail.
The reality is that I had a job and didn't do anything I shouldn't have. But my parole was revoked because of this one woman’s crusade against the very medication that helped me keep a job, pay my bills and not commit any more crimes.
I am sure there are many more stories like my own. The parole and probation system desperately needs to be educated. I would like to address this group someday and tell them that different treatments work for different people. Methadone has gotten me away from drugs and crime.
Thank God I am no longer on parole. The minute I got off parole, I went back on the methadone maintenance program and haven't had so much as a traffic ticket since then.
Editor’s note: Legally speaking, the issue of methadone maintenance treatment and parole/probation is somewhat complicated. In theory, the terms of one’s parole or probation are what counts--and these are determined by the judge, or at least, the judge must give final approval of any probation or parole terms. Absent something in the terms specifically prohibiting maintenance treatment or use of prescription opiates, the individual is free to take methadone or any other prescription medication that has been legitimately prescribed by a physician.
Not surprisingly, there are judges who are strongly against methadone maintenance treatment and may make terms precluding it; for example, a judge could make it a term of the probation that the individual undergo a specific detoxification treatment. Hopefully, advocacy organizations such as Detroit Organizational Needs in Treatment (DONT) and Advocates for Recovery through Medicine (ARM) can work to educate judges, as well as parole/probation officers about methadone maintenance treatment. It has been well-established that methadone maintenance treatment drastically reduces criminal activity, so the criminal justice system should see it as a positive.
In general, we are of the opinion that judges and parole/probation
officers should not be playing doctor period. They should never prevent
or punish an individual for receiving medical treatment of any kind.
According to Marilyn Miller, the Michigan SMA is not able
to give 14- and 30-day take homes to methadone patients at this time.
Ms. Miller has stated that any changes in Michigan’s regulations must go
through the Michigan legislature.
If you are interested in helping educate legislators about methadone or forming a committee to help the process of changing Michigan’s regulations along, please contact me at the address or E-mail address on page four of this newsletter, or call (810) 658-9064. If patients don’t speak up about wanting extended take homes, we should not lament later.
I need your help. As Director of DONT (local) and ARM (national),
my time is very limited, even though I put in many, many hours. Aaron
Rolnick (Managing Editor of Methadone Today), bless his heart,
gets dumped on a lot because we haven’t had much support in Michigan.
That’s partially my fault because I haven’t had time to develop local membership,
but if you want to help, I’m no farther away than an E-mail or a phone
call. It’s up to you, and it’s for your benefit.
- Beth
The media has finally started reporting what we already knew--that many opiate addicts are addicted to prescription painkillers rather than heroin. Moreover, a number of methadone maintenance patients were addicted to these prescription opiates (a common misconception is that opiate maintenance treatment is only for heroin addicts). Metro Times, a free, Detroit-based publication that enjoys wide circulation in the area, published an article in its June 12 issue, “In Vicodin’s Grip,” by Curt Guyette. The article documents the recent upswing in abuse of prescription painkillers such as Vicodin and Oxycontin.
Hopefully, these media reports will create a greater understanding of opiate addiction and addiction treatment. According to the Metro Times article, many people, including individuals abusing prescription opiates, do not even realize that prescription opiates are chemically very similar to heroin. In fact, many prescription opiates are extracted or derived from the opium poppy. Heroin is not present in the opium poppy, but morphine is. . ., and morphine is easily converted to heroin [diacetylmorphine], its chemical cousin. Prescription opiates can cause the same type of addiction and physical dependence as heroin. The severity and duration of withdrawal may vary, but the symptoms are similar.
The Metro Times article also correctly points out that many opiate addicts, including those who eventually receive maintenance treatment, were first exposed to opiates when being legitimately treated for pain. For the article, they interviewed a man who became addicted to Vicodin after being prescribed it for only a 6-day period for pain related to kidney stones. The message being sent to readers is that most opiate addicts did not “choose” to become addicted--by no stretch of the imagination did this man plan or choose the disease of opiate addiction. He apparently took his prescribed medication as directed and was not taking them with the intention of getting “high”. Readers are informed that a small percentage of people are “genetically predisposed” to drug addiction; drug addiction is essentially a disease caused by a chemical imbalance in the brain and not a choice or a moral deficiency. More articles like this one may change the general public’s view of opiate addiction and opiate maintenance treatment.
Unfortunately, the Metro Times article sent the wrong message regarding the prescription of opiates for pain relief. They seemed to blame the upsurge in prescription painkiller abuse on the current, more enlightened pain management attitudes among physicians. However, Dr. McCarroll, a nationally recognized expert on addiction, recognized that the media hype “could cause physicians to stop prescribing a useful medication to people who legitimately need it.” He added that physicians need to be more forthright in warning patients of the potential hazards of addictive drugs, they need to become more adept at recognizing the signs of addiction, and treatment has to be readily available.1
The benefits of adequate pain management definitely outweigh the
low probability of developing an addiction to opiate medications.
Metro Times does quote NIDA (the National Institute on Drug Abuse),
that opiate medications are safe and effective when taken as prescribed
but do not go nearly far enough in stating the benefits of proper pain
management. Researchers have found that patients heal faster and
function better when their pain is adequately managed. Besides, allowing
people to suffer when safe and effective pain medications are available
is inhumane. For years, physicians have been frightened out of using
opiate pain medications by overzealous drug enforcement and exaggerated
claims regarding the risk of addiction--media misinformation should not
be permitted to thwart enlightened treatment of pain.
1Dr. McCarroll is the Medical Director of Bio Med (22900 E. Remick),
a methadone maintenance clinic in Clinton Twp. Methadone maintenance is
the “gold standard” in the treatment of opiate addiction, and Dr. McCarroll’s
clinic, based on a medical model, is the best in Michigan. If you
feel you are addicted to opiates (prescription or otherwise), call Bio
Med at (810) 783-4802.
For example, in Washington, D.C., ARM-DC plans to write a grant proposal based on starting OBOT practices. ARM-DC plans to contact area doctors, both by mail and by asking current methadone maintenance patients to ask their own private doctors in order to find a pool of doctors who are interested in starting OBOT practices. Then, ARM-DC plans to work with the DC SMA to set up a “health department as hub” OBOT model. The model can be seen in the “Physicians Guide to OBOT” at the ARM web site: http://www.arm-advocates.org.
These grants can be up to $400,000, but grant applications for less than $100,000 can be submitted at any time. ARM-DC anticipates that $100,000 will do nicely to start our OBOT project.
You can do the same in your city. Check out the foundation’s web site at http://www.saprp.org. Letters of intent to apply for this grant are due by August 20.
