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Methadone Today’s Six Year Anniversary - Aaron Rolnick
Prosecution of Doctors May Harm Patients
Guide to Medications Used in Opiate Addiction Treatment (part 1) -
Antabuse Found to Reduce Cocaine Abuse -
Pregnancy, Methadone, Anesthesia - August 2001, Vol VI, No. VIII
Exactly six years ago, the first issue of Methadone Today was printed. With a little help from the staff at their methadone clinic, a few dedicated patients organized a newsletter to educate and advocate for methadone patients.
In large part, Methadone Today and DON’T (Detroit Organizational Needs in Treatment, the local methadone patient advocacy organization who publishes Methadone Today) were created in response to a DEA raid that took place at a local methadone clinic. For the alleged actions of the clinic’s owner, the DEA reportedly stormed the facility with guns a’blazing. Put simply, the DEA approached the methadone clinic--a provider of a legal medical treatment--as they would a crack house with armed occupants. Patients and clinic staff [who had done nothing wrong or illegal] were forced to lie down on the ground at gunpoint. Private counseling sessions were interrupted and confidential patient records were seized.
There is no doubt that this raid could have been carried out in a manner that allowed patients and staff to maintain dignity and without sacrificing patient confidentiality. Why didn’t they just wait until clinic hours were over and the staff and patients had left? The patients who started Methadone Today could not help but think that this type of raid would never have been conducted on any type of medical establishment except a methadone clinic (absent extenuating circumstances--where hostages have been taken or an armed robbery is in progress). These patients were tired of the myths and stereotypes associated with methadone maintenance (i.e., that it was not a real medical treatment, that it was just “substituting” one addiction for another, etc.), and decided to take action by educating people about methadone treatment.
Within the six years that Methadone Today has been published, more than a few changes have occurred in opiate addiction treatment--especially in the last year or two. For example, Buprenorphine, though not yet approved by the FDA, has emerged as an opiate addiction treatment; UROD (rapid detox) has become more available, and new federal regulations have changed take-home rules and other aspects of opiate maintenance and detoxification treatment. During the past six years or so, understanding of proper treatment practices has increased in areas including adequate dosing (findings that some patients may need much more than 120 mg/day of methadone), medical/office-based maintenance treatment, pregnancy and breast feeding (research indicating that maintaining on relatively high doses of methadone while breast feeding or pregnant is completely safe, and dose reductions during pregnancy is risky to the health of both fetus and mother), etc.
We have tried our best to educate our readers and cover a wide variety of topics related to methadone maintenance treatment and other pharmacological opiate addiction treatments. We have attempted to maintain a balance--between patient stories, articles about treatment practices, and doctors’ answers to specific questions about treatment. To our Medical Advisory Board, thanks for your help and contributions to Methadone Today.
You may have noticed that some of the articles do not deal with aspects of treatment per se; for example, we have printed articles on legal issues (i.e., the Americans with Disabilities Act) and health insurance coverage of treatment. We realize that every reader will not find every article helpful, but we hope that you have found at least some of the articles useful. If nothing else, we want you to know more about opiate addition, treatment of opiate addiction and related issues than before you read an issue of Methadone Today.
We would also like to find out your opinion of the newsletter.
Have we neglected certain issues that you believe we should focus on?
Do we print enough patient stories? Actually, we would like more
patients to send in their stories for us to print. Send us your comments!
Our address is on p. 4.
If you feel you have gotten something out of Methadone
Today, we ask you to consider purchasing a subscription or making
a donation if you haven’t already. Methadone Today
is supported strictly by subscription fees and donations. We do appreciate
the small number of methadone clinics who purchase group subscriptions,
and we hope to see more clinics willing to do this. But if you have
been picking up a copy of the newsletter at your clinic, chances are that
your clinic did not purchase it--we provided it for you. In
such cases, subscribers and donors are actually paying for your “free”
newsletter. If you like what you are reading and can afford to pay,
we urge you to purchase a subscription. The newsletter will be sent
to your home; you don’t have to worry about missing an issue, and you can
feel good knowing that the subscription dues will help keep it going and
reaching new patients and others.
We need to stress that no one is paid for work on this newsletter and/or patient advocacy. However, the printer, post office, phone company, etc. are not so altruistic. They insist upon being paid. Please do your part. If not you, who? If not now, when?
DRCNet reported* on federal raids and prosecutions on three Virginia doctors for allegedly prescribing Oxycontin “for no legitimate medical purpose.” Whether these doctors are truly guilty of “pill-pushing”, these federal actions will make it even harder for patients who really do need pain medication to find a doctor willing to adequately medicate them. One can hardly blame doctors for shying away from prescribing adequate pain medication when overzealous law enforcement agents continually monitor and scrutinize any physician who aggressively treats pain or sees a large number of pain patients--especially when conviction will result in their losing their medical license and, perhaps, them going to prison.
Worse yet, this article calls into question whether the doctors even received/will receive a fair trial: “This assault on pain doctors as scrip-happy Dr. Feelgoods comes amidst a local level of concern over Oxycontin abuse that approaches a classical moral panic. With police and prosecutors hyping the threat of Oxycontin abuse and local newspapers faithfully parroting what they hear from law enforcement officials, local juries are quick to convict, and local authorities are quick to conjure up new solutions to the latest drug menace.” When the public is whipped into this level of hysteria, it would not be surprising if juries were to convict doctors who were doing nothing more than adequately treating pain.
Unfortunately, doctors who are known to aggressively treat pain are sometimes targeted by drug addicts and/or dealers, who attempt to obtain pain medication for non-medical use by lying to doctors about having pain ,etc. If anyone is held responsible for the prescription of pain medication under false pretenses, shouldn’t it be the patient–the one who deliberately lied to get medication s/he didn’t really need? The issue of responsibility aside, the result of overzealous prosecution of doctors prescribing pain medication and [in the context of public hysteria] jurors eager to convict, is that some good doctors will be punished--and in the end, patients in need of pain medication will suffer.
Why are we writing about this in Methadone Today? Methadone maintenance patients sometimes require pain management occasionally for long-term or chronic pain. If these federal actions make it difficult for individuals who are not methadone patients or opiate addicts to obtain adequate pain treatment, it makes it nearly impossible for methadone maintenance patients to obtain adequate, or sometimes any, pain treatment.
The prosecutions reported in this DRCNet article relied heavily on the testimony of a handful of patients who were abusing the medication prescribed by the doctor who was being prosecuted. Thus, somewhat understandably, doctors are afraid that if they prescribe strong narcotic pain medication to a methadone maintenance patient or any opiate addict, that patient is going to give the same kind of testimony--something to the effect of, “the doctor prescribed Oxycontin even though he knew I was an opiate addict....” Add that to the common misconceptions held about pain management in methadone maintenance patients, and no wonder many doctors will under medicate or even refuse to treat methadone patients with pain issues.
One of the scariest elements of this story was revealed when the doctor testifying for the prosecution expressed his opinion on the prescribing of pain medication to drug addicts. According to DRCNet, “...in Dr. [Adam] Steinberg's opinion, no one with a drug problem should be given opioids for pain. ‘It's not a legitimate medical purpose to issue a narcotic for a known drug abuser,’ he testified.” DRCNet correctly pointed out that this opinion is sharply at odds with the opinion of experts in the area of pain management and the position taken by various [medical] professional organizations. But it doesn’t take an M.D. to see that the consequence of doctors acting on such an opinion is inhumane treatment. In many cases, the only adequate treatment available for serious pain is the provision of opioid medication.
NSAIDs (non-steroidal anti-inflammatory drugs) can be used in cases of mild to moderate pain and/or where the anti-inflammatory effects of such medications will help reduce the amount of pain, but there are cases where NSAIDs are not sufficient to relieve pain--plus, the use of NSAIDs is risky in patients with liver problems.
Despite medical advances, there are many instances where opioid medications are the only decent treatment available for pain. It is discouraging that the Dr. Steinbergs of the medical community get recognition and respect [while providing inhumane treatment to patients in pain who happen to be drug addicts], while doctors willing to aggressively treat pain are subject to harassment and character assassination. Perhaps Dr. Steinberg should be the one losing his medical license instead of those few doctors willing to adequately treat patients that other doctors won’t even accept as patients?
Editor’s Note: In an interesting twist, DRCNet reported that Dr. Freeman Clark, one of the doctors tried and convicted of prescribing Oxycontin “for no legitimate medical purpose,” had abused prescription drugs. This was revealed at the trial, and even though he had not misused such drugs since 1999, as confirmed by random drug screens performed periodically between 1999 and now, this apparently was a factor in his conviction.
This appears to be another case of prejudice against drug addicts;
the fact that this doctor abused prescription drugs at one time does not
make it any more likely that he was guilty of mis-prescribing pain medication
to others. It seems that the jurors jumped to certain conclusions
based on certain negative myths and stereotypes about drug addicts.
I managed to get and stay clean for 18 years and became an RN. But due to stress and the fact that I got sick of AA/NA totalitarianism and stopped going to meetings, I eventually started using again. It took two years for me to decide (after several failed self-detox attempts) to go on methadone. I had even worked in a methadone clinic and stayed clean. Saw quite a few people detox off of methadone slowly and thought that was what I would do.
It didn't work out that way. I have Hepatitis C and turned out to be an extremely fast metabolizer of methadone. In six months I went from 20 mg to 175 mg. Was having disabling side effects from the methadone, so I decided to detox. Had a hell of a time finding a place that would detox me, and I knew the horror stories (bless your heart!) of UROD, so I was determined not to go that route. But I realized by this time that I wasn't going to be able to detox slowly. I couldn't even get stabilized; every two weeks I'd start feeling sick again and ask for a dose increase. I asked my doctor at the clinic what the criteria were to determine if methadone would not work for someone. She said, "I have never encountered a patient that methadone wouldn't work for”--and yet on their web page, it states that "methadone treatment isn't for everybody."
Detoxing off of 175 mg of methadone in 12 days was hell. The detox center I went to tried to do it in six days, and on the 7th day, I had to literally beg them to give me some more methadone--and they only did it because my blood pressure had gone dangerously high. I managed to go two days without any medication except clonodine, in terrible agony (couldn't get out of bed, etc.). On the third day, I demanded that the M.D. extend my taper, which he did after I pressured him. I was told by their sales office that I would be detoxed comfortably. They told me all the lies that they could think of to get me there, and I was desperate, so I bought it--for $6,000.
(Cont p. 2)I started doing some research, and what I found was 1) hydrocodone addicts statistically get to higher stabilization doses than heroin addicts, even though they come into treatment at lower doses and 2) addicts with hepatitis C infection tend to be fast metabolizers (especially if they have progressed hepatitis C; I have had it for over 30 years) and many will need split dosing and higher stabilizing doses.
I guess the point I am making is that there are risks to methadone treatment that weren't adequately explained to me. Every medical treatment helps some, leaves some the same, and makes others worse. I unfortunately happened to be in the latter catagory. I have now been off methadone completely for about five weeks and have relapsed twice, partially because I am an "addict" and have whatever brain disease that entails and partially because I am still in "withdrawal"--the physical pain (related to endorphin deficiency?) is simply unbearable at times. I've considered going back to methadone for the short term relief I would get, but I also believe that I would end up where I was before: totally clouded mentally, needing increases every two weeks, always trying to keep in mind when I needed to drink my next dose and having to carry doses in public.
I have seen others develop some of the same problems I did at high dosages of methadone. I would have definitely been better off detoxing off of the hydrocodone. Don't know if I would have stayed clean--probably not, but maybe would have made it until buprenorphine became available. I've wondered if it would be a better approach for relatively low-tolerance opiate users.
Again, thank you for your fine work. My letter is not in criticism of
methadone treatment--I've seen it work for many, but it does not work for
every narcotic addict. -George
Dear George,
We would tend to agree with you that methadone maintenance treatment will not work well for every opiate addict, even with excellent care from a knowledgeable physician. The doctor who said, "I have never encountered a patient that methadone wouldn't work for,” may have been telling the truth--this doesn’t mean that it works for absolutely ALL patients.
In our experience, the problems you talk about with methadone maintenance treatment are pretty rare--but clearly there are patients who cannot stablize and function on methadone treatment. A much more common difficulty we see is that the patient could do well on methadone with the proper treatment but are not getting it. Worse is that Hepatitis C limits your treatment alternatives.
We cannot speak for the “others” whom you state have developed some of the same problems you experienced at high methadone doses, but we have yet to see research or anecdotal evidence that suggests that patients on relatively high doses have more problems than patients on lower doses. Your diffficulties likely stem from an inability to stablize on methadone at any dose--not from taking “too high” a dose. To put it another way, your real problem is that you bounce between intoxication and withdrawal--you even indicate in your comments that people observed that you looked intoxicated but that at the dosing window you were sick.
Instead of looking at this as a criticism of methadone maintenance treatment,
we see this as part of the “one size fits all” problem. There are
just not enough good, legally available alternatives for the people who
do not succeed on methadone maintenance treatment--perhaps because they
are very fast metabolizers of methadone or because they experience excessive
side effects. This is part of what the Swiss heroin maintenance trial
was about: the participants had already failed at methadone maintenance
treatment for a variety of reasons. In Germany, codeine has been
used for maintenance purposes--this may be a better medication in a small
number of opiate addicts.
*Per federal regulations, an individual has to be addicted to opiates
for a minimum of one year before obtaining maintenance treatment with methadone
or LAAM. Minors may obtain methadone maintenance, but additional
prerequisites apply, including parental consent.
.
The National Institute on Drug Abuse (NIDA) reported in their March newsletter* that Antabuse, a medication typically used for alcohol treatment, may help reduce cocaine use in opiate-addicted persons when combined with Buprenorphine.
The study included patients who abused cocaine and were being treated with Buprenorphine for their opiate addiction. Half of these Buprenorphine patients were also given Antabuse (disulfiram), and the other half received a placebo. The study showed that patients who took Buprenorphine and Antabuse "achieved... continuous abstinence from cocaine faster and stayed abstinent longer than those who received only Buprenorphine."*
An earlier study found that Antabuse also reduced cocaine use among methadone patients who use cocaine but little, if any, alcohol. More studies are planned. Researchers are seeking to understand exactly how Antabuse works to inhibit cocaine use in opiate-treatment patients. They hope this will lead to the development of a new class of cocaine treatment medications.