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Volume III, Issue V (May 1998)
Methadone Success Stories: Going Public - "Gina
Inmates on MMT - Aaron Rolnick
Dear Readers - Denise, Montevallo, Alabama
TIP/TAP Series - MMT in Jails & Prisons - Nancy Rose (DONT Secretary)
NAMA Column - Joycelyn Woods
Doctor's Column - Addiction/Dependence: there is a difference
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Methadone Success Stories: Going Public
I found a copy of a newspaper article from the New York Times written
by Christopher S. Wren floating around our clinic. The title was cut off, but the
sub-heading read: "Greatest Success Stories Go Untold Because of Stigma."
The article is about a musician, Jimmie Maxwell, a veteran jazz trumpeter, who has
played with Benny Goodman, Lionel Hampton, Duke Ellington, and Gerry Mulligan. He
also worked as a studio musician on the Perry Como show and Johnny Carson's Tonight
The main point of the article is that Mr. Maxwell finally went public
with the fact that he has been a methadone patient for 32 years! He
is presently 80 years old. Mr. Maxwell tells how heroin addiction nearly killed
him 32 years ago, but he has stayed "clean" for the past 32 years by staying
on the medication methadone (He had joined Dr. Marie Nyswander's original
program back in 1965!) He hid it for years from his employers and fellow band members
because of the stigma attached to a treatment for heroin addiction.
Wren estimates that over 115,000 Americans take methadone daily. He also explains
there is "...an insidious social stigma that equates methadone with illicit
drugs, forcing users to hide the achievement of taking back their lives."
Mr. Wren quotes several physicians in the article. Dr. Edwin Salsitz (director of
the methadone medical maintenance program of Beth Israel Medical Center in New York
City) said, "Successful methadone users are invisible; methadone is always judged
by the failures." Dr. Salsitz equates methadone for opiate addicts as insulin
is for diabetics (in other words, the medication corrects faulty brain and/or body
chemistry). Dr. Robert Newman (president of Beth Israel Medical Center) said, "The
safety and efficacy of methadone in the treatment of narcotic addiction have been
documented more extensively than any other medication in the pharmacopeia."
Dr. Mary Jeanne Kreek (an early colleague of Dr. Nyswander) said that when the very
first patients were given...methadone daily, "...they began turning away from
[illicit] drug administration and getting on with their lives".
of us methadone patients today are still afraid to let employers, friends, or others
know we are on methadone. Some are even reluctant to let family members know.
But, we should be PROUD that we chose to recover from our addiction, that we are
able to live "clean" because of this life-saving medication! Hopefully,
with all the advocacy groups sprouting up locally, nationally, and internationally,
more famous people or professionals (doctors, nurses, teachers, lawyers, etc.) will
go public with the fact they are methadone patients. Then, maybe the rest of us
patients will feel we can "go public".
So please, any of you methadone
patients who can "risk" educating people, please do so! Yes, it can be
embarrassing to tell people we were once a using-addict. It's certainly understandable
if you feel you don't want to offer this bit of personal history, since many people
can be judgmental. But, we can start with the people who did know
us as addicts; let them know (and see for their own eyes!) how much you have improved
your life by seeking treatment and taking this life-saving medication. If you see
a TV program or read an article that is biased against methadone, write a letter
(anonymously, if necessary) to tell them the truth! Most of the media
only tell about the small percentage of methadone patients who aren't doing well.
(Christopher Wren is an apparent exception, along with Rolling Stone Magazine; both
have written honest articles about methadone and methadone patients. Additionally,
Rolling Stone has written about harm reduction and other drug policy issues.)
All of us thousands of methadone patients who have turned our lives around and presently
are working, going to school, raising families, voting, and paying taxes are invisible
to the general public. If we don't educate the rest of the world, who will?
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Inmates on MMT
by Aaron Rolnick
Jails and prisons often will not provide methadone to inmates (on MMT prior to
incarceration), yet such jail/prison actions are rarely challenged in court. In
the August 1996 issue of Methadone Today, "Sad Tales From Nassau
County Jail" by Donna Schoen compiled a set of stories by several inmates of
the cruelty they were forced to suffer as a result of the jail refusing to provide
methadone to them or rapidly detoxing them despite being maintained on methadone
prior to incarceration. Although all the stories came from the same jail in Nassau
County, New York, the editor of Methadone Today made sure to point
out that, "Any city, Anywhere, USA could be substituted."
Unless a particular state has legislation requiring jail and/or prisons to dose
inmates on methadone or even setting standards for detoxing inmates on methadone,
jails and prisons with a few exceptions have a great deal of leeway in detoxing/dosing
inmates on methadone.
Anyone who has suffered the debilitating symptoms of
withdrawal syndrome knows that enduring the pain and suffering of it is like being
tortured. Jails and prisons that withhold an inmate's dose technically are not directly
inflicting pain and suffering, but withholding necessary medication makes the jail/prison
as responsible for the pain and suffering as if a jail/prison employee had beaten
an inmate. Furthermore, a jail or prison withholding necessary medication resulting
in severe withdrawal syndrome is just as cruel as any direct act of torture. Not
even considering the possibility of relapse, depression, and even suicide, cold turkey
withdrawal or even a 6 day detox from a very common dosage of 100 mg. of methadone
would result in severe physical withdrawal symptoms that would probably be more painful
than, for example, a flogging, a practice that would not be allowed in a U.S. jail
or prison. Thus, jails and prisons should be prohibited from forcing
an inmate to go through cold turkey withdrawal, detox at an untherapeutic rate, or
even involuntary detox at all.
Contrary to the notion that withholding medical
care from inmates is, or at least should be, considered unconstitutional "cruel
and unusual punishment" pursuant to the 8th amendment to the U.S. Constitution,
the courts have only recognized a limited right of an inmate to medical care. The
courts have used two different standards to determine the rights of inmates:
one standard for "pretrial detainees" (those held in jail or prison awaiting
trial) and another less stringent standard for those already convicted and serving
The U.S. Supreme Court addressed the rights of convicts to medical
care in Estelle v Gamble (1976). In Estelle, the Court
ruled that failing to provide a convict with medical care only violates the 8th amendment
if: 1. The denial or delay of medical care is deliberate. 2. The medical needs
that are not tended to are serious (failure to address medical needs will result
in sufficient harm to the convict). Unfortunately, these standards are very stringent
and quite difficult to prove. Obviously, most jails and prisons are going to do
just enough to demonstrate that any inadequacy in a prisoner's medical care will
not be found to be "deliberate"; in Estelle, the Court explains
that, "an inadvertent failure to provide adequate medical care" would not
violate the 8th amendment (if it's not "deliberate," then it must be "inadvertent"
and permissible). Thus, even medical malpractice would be allowable, as long as
the inadequacies were not intentional.
Given the above standard for determining
whether denial of medical care constitutes a violation of the 8th amendment, the
likelihood of a jail or prison withholding methadone from a convict being ruled unconstitutional
is very low. As long as the inmate is examined by a doctor at some point, the jail
or prison is probably under no obligation to provide methadone, and at very most,
may be required to provide minimal medication to ease withdrawal symptoms.
The degree/standard of medical care that jails and prisons are constitutionally required
to provide pretrial detainees has not been clearly established by court decisions.
Unless a court case has already established that a medical treatment (or lack thereof)
is cruel and unusual punishment, the court must decide whether the treatment/denial
of treatment should be considered a punishment. In Allegheny County Jail v
Pierce (1979), the Court declared that absent an expressed intent to punish,
if a restriction of pretrial detention is reasonably related to insuring jail security
or making sure the prisoner attends trial, it is not unconstitutional "punishment".
On the other hand, if the restriction of pretrial detention is "arbitrary or
purposeless," then the action is considered unconstitutional punishment and
may not be inflicted upon the prisoner.
The Federal Courts have made different
and sometimes conflicting determinations of whether or under what circumstances jails
and prisons may rapidly detox or simply refuse to dose a pretrial detainee who was
on methadone maintenance before being incarcerated. In Cudnik v Kreiger,
the (District) Court determined that jails and prisons do not have a legitimate reason
to withhold methadone from methadone maintenance patients and therefore, it is unconstitutional
for them to detox a pretrial detainee at all. In Norris v Frame, the
Court (of Appeals) reasoned that there could be a legitimate reason to withhold/limit
methadone, but whether there is depends on the circumstances--if a jail or prison
had dosed inmates in the past, the Court doubted that the jail or prison all of a
sudden needed to withhold methadone for security or other legitimate reasons. On
the other hand, many courts have ruled that jails and prisons have a legitimate security
interest (albeit weak) in withholding methadone from pretrial detainees and have
allowed detox or even a complete withholding of methadone (at least if tranquilizers
and/or other medications are used to somewhat ease withdrawal): Allegheny
County Jail v Pierce, Owens-El v Robinson.
The courts have virtually
eliminated the rights of convicts and have limited the rights of pretrial detainees
who are methadone patients to maintain on methadone. The preponderance of Federal
Appeals Court decisions have permitted jails and prisons (at least under certain
circumstances) to a minimum, limit a pretrial detainee's access to a short (6 day)
detox. Fortunately, the courts have not yet set this in stone, and since the U.S.
Supreme Court has not ruled on this issue, pretrial detainees may still be able to
obtain a fair hearing. Thus, if a medical expert could convince the court that given
the relapse rate and severity of physical withdrawal symptoms that a jail or prison
forcing a detainee to detox is not reasonable, it would indeed constitute punishment.
The US Supreme Court has not taken any such methadone cases,
so until/unless they do, the lower federal courts are left to determine whether jails/prisons
are allowed to withhold methadone from pretrial detainees. In the US Sixth Circuit,
which includes Michigan, no such methadone case has reached the Court of Appeals.
The only such case within the Sixth Circuit reached a US District Court in Ohio:
Cudnik v Kreiger. A District Court is inferior to a Court of Appeals
and therefore not binding on a Court of Appeals. However, the courts generally prefer
to remain consistent with other courts and court decisions within their circuit.
Therefore, other district courts within the Sixth Circuit, as well as the Sixth
Circuit Court of Appeals, may be persuaded to follow the decision of the Court in
Cudnik v Kreiger. Fortunately, in that case, the Court ruled in favor
of the pretrial detainee, agreeing with them that jail/prison security is not advanced
by withholding methadone from inmates and, therefore, was punishment and in violation
of the detainee's constitutional rights. Thus, pretrial detainees in Michigan and
the Sixth Circuit may be able to successfully sue to obtain methadone maintenance
by persuading the courts to follow Cudnik v Kreiger.
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by Denise, Montevallo, AL
Dear Readers: I am a fifth-year methadone patient. I am also an
addict with a 20-year history of drug abuse. There's not much I haven't been through
relating to addiction. I did, however, manage to hold onto my home, job of 15 yrs.
and child. Methadone saved my life.
Last year, I was really put to the test.
After four years of successful methadone maintenance, I "fell," so to speak.
During a time of extreme stress, I reached back into my old habits and took several
Valium. My mother had a stroke, and my father is terminally ill with cancer. Being
the total caregiver for both, I was reaching for some relief. Did I ever look in
the wrong place.
To make a long story short, I was arrested. I do not take
Valium on a regular basis; this was the second time I had taken them in five years.
I do have a previous arrest for possession for which I received 15 years probation.
I made almost four years before I was caught for DUI, Valium (2), and pot (2 joints).
I paid a lawyer $10,000, for which he said I was lucky to receive a split sentence--2
years in jail and 10 on probation.
I don't feel "lucky." Now I
am faced with coming off methadone immediately; this is my eighth day without any
medication. My thoughts are, "If I have to detox immediately, I'd prefer to
do it at home."
Anyhow, my reason for writing is to let you know it
only takes one slip to put you where you do not want to be. Every month when I receive
the newsletter, I thank God above that there is someone out there who feels as I
do. This is my assurance that I am not alone. Many, many times I've wanted to tell
Beth Francisco what her work and dedication has meant to me "hands across the
miles" so to speak. Nevertheless, I never got around to just saying, "Thanks,
When my problems arose, I immediately thought of Beth--if anyone
would know how I could be helped, it was she. When I called her, it was quite early.
She took a deep breath and listened quietly to what I had to say. She also offered
encouragement, helpful information, and basically friendship.
So, here I
sit wondering why I waited to tell her how very much she is appreciated. I've never
met her, but the kind concern she has shown to me is something that is all too rare
in this world in which we live. Not only did she listen quietly while I sobbed--after
an hour or so of encouraging words, she spent the rest of the day preparing detailed
information that would be helpful to me. This, to me, is the caring attitude that
I wish more people in the world would exhibit. Now not another day shall pass before
I must say, "Thanks, Beth. Your kind and gentle concern does not go unnoticed.
- Denise; Montevallo, AL
Editor's Note: Denise
wishes there were more caring people--there are many, and they are working long,
hard hours to put an end to the insanity. The names are endless: Aaron, who researched
"Inmates on MMT"; Nancy, who is writing the TIP & TAP Series; Ken,
who has been ill but keeps on taking complaint calls; the great doctors in the Doctor's
Column; Liz M, Bill R, Jimmie P, Jessica D, Katherine B, Joycelyn, Diane S, Judith
O, Maia, Odus, Rokki, Magic, Nick M, Floyd L--the list goes on...
aches for Denise. She is no criminal, but she does put a human face to addiction
and the addict in prison.
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TIP/TAP Series - MMT in Jails/Prisons
by Nancy Rose (Secretary, DONT)
This is a new column that will run for several months and will bring you information
straight from the U.S. government's TIP & TAP Series. Both the TIP and TAP
series of books are put out by the U.S. Department of Health and Human Services.
TIP stands for "Treatment Improvement Protocol" series, and TAP for "Technical
Assistance Publication" series. There are about 25 books in each series--available
free by calling 800 SAY NOTO and asking for them.
Each book begins
by explaining that it contains the "state-of-the-art protocols and guidelines
for the treatment of alcohol and other drug abuse" for the nation's substance
abuse treatment programs. The TIP & TAP books are written by a number of professionals,
including "acknowledged clinical, research, and administrative experts"
and other experts in the field. CSAT puts together a Federal Resource panel to review
each book after it is written, which then has to be approved by several different
groups of professionals, including a non-federal consensus panel and a group of "expert
field reviewers" before being finalized and accepted as the government's official
Several of the TIP & TAP books are specifically on Methadone
Maintenance Treatment (MMT); some of their titles, for example, include: "Treatment
of Opiate Addiction with Methadone - A Counselor's Manual" (TAP #7); "State
Methadone Treatment Guidelines" (TIP #1); and "Matching Treatment to Patient
Needs in Opioid Substitution (Methadone) Therapy" (TIP #20). Topics of some
of the other books include LAAM and treating pregnant women, adolescents, and drug-exposed
For today's topic, I have searched through the TIP & TAP books
for the federal government's recommended guidelines regarding methadone treatment
for patients who are incarcerated in jail or prison. TIP #19 ("Detoxification
from Alcohol & Other Drugs"), page 37, states: "Persons who are incarcerated
or detained in holding cells or elsewhere should be assessed for physical dependence
on alcohol, sedatives-hypnotics, and/or heroin. Untreated withdrawal from alcohol
or other sedatives/hypnotics can be life threatening. Heroin withdrawal is not life
threatening to an individual who is healthy (emphasis mine); however,
it may be difficult for the patient. Individuals who are on methadone maintenance
may experience severe withdrawal symptoms if the medication is abruptly stopped.
Persons who have been on (methadone) maintenance therapy before being incarcerated
should continue to receive their usual dosage of medication (emphasis
mine) if the expected period of incarceration is less than two weeks. If incarceration
is longer, the maintenance therapy should be gradually discontinued....There may,
however, be restrictions on the use of methadone...in a prison setting. In such
cases, staff may need to create linkages with local methadone...programs."
Now, there are some people who believe that if an addict gets locked up (guilty
until proven innocent?), he or she "deserves" to suffer from withdrawal.
But, any one of us--and this includes all law-abiding citizens, be they MMT patients,
clinic staff, or others--could unexpectedly find ourselves locked up and charged
with a crime even if innocent. It happens every day, folks--mistaken identity, police
raiding the wrong address, being in the wrong place at the wrong time, etc. ALL
of us should be concerned about our rights if we should happen to get locked up.
Every citizen has a right to their medication, whether it's methadone, insulin,
or whatever. Even the federal government recommends this in their guidelines
and protocols in the TIP & TAP books.
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Perhaps the one important event this past month was the Moyers Special, "Close
to Home" that aired on PBS. On the down side was the emphasis on groups and
the one researcher who made a statement that inferred morality and the need for spirituality
to recover. The young boy was perhaps the best thing about the entire show for methadone
when he looked directly at the camera and said that he wished his father would get
on the methadone program (because his mother had made so much improvement since beginning
MMT). "Close To Home" is the first step in destigmatizing addiction and
correcting the public's belief that it is a behavioral problem. It will be up to
us to use the momentum from "Close To Home" to educate the public, policy
makers, social workers, health professionals---everyone! A big task, and now we
have some help.
Each month we will ask all of our
members (this includes you, the reader) to write a letter to a specific politician
or policy maker. It can be the same letter each month because different individuals
will receive it. So once you write your letter, you can use it over and over again.
And you don't have to worry about typing it; in fact, if you do it in your own handwriting,
the letter will be taken far more seriously because they know you took the time to
write it. So the target group for April is your two Senators in Washington. Last
month, it was the House, so this month we will complete the federal part of this
letter writing campaign, at least for now. When you write, be sure to drop Methadone
Today a note saying "I wrote to my senator this month." We will forward
the information to NAMA. This is the way we will keep tally of the number of letters.
Nothing like this has ever been done before, and if each senator receives even a
few letters, it will make a tremendous impact. Editor's Note: Thanks to everyone
who sent the letters which were in the February 1998 Methadone Today (although we
sent "thank you" letters to those who informed us that they participated,
some did not give us their address, so we thank you now). If you did not send the
letter, you can use it now or at least get some ideas from it. Please do your part,
and send one this month.
April 22nd was the First Annual Syringe Exchange
Lobby Day. Thousands of activists went to Washington to talk with their representatives.
It is not too late to do your part--you should call, write a letter or send a fax
to your representative and senator--yes both--and if you have the time, you might
write to Health and Human Services Secretary, Donna Shalala, and President Clinton
asking them to lift the federal funding ban on needle exchange. Of course, you can
add that Methadone Maintenance Treatment needs to be made available to every addict
and American citizen who needs it, NOW. Addicts and their loved ones should not
be abandoned because the public does not understand addiction.
I am consistently getting phone calls, letters and messages
on the Internet from patients who do not realize that they are protected by the Americans
With Disabilities Act (ADA). They are frightened and feel trapped. Just recently
I received a call from a patient who was told by staff that they had better withdraw
from methadone treatment before getting a teacher's license. Clearly this so-called
methadone professional is ignorant about the consequences of withdrawing from treatment.
A patient should never, never withdraw from methadone because of a job or family
or any reason that does not come from you--you do it because you and you alone want
Patients who withdraw from methadone usually relapse, no matter their
stability or what they have achieved. So when such an idea is presented to a patient
who is obviously not ready, it suggests to me a severe lack of education and misunderstanding
about addiction. Yes, these people are dangerous to us, and there is no excuse for
their lack of education with the wealth of information about methadone that is available--and
most is free! Obviously this staff person does not realize that former addicts and
methadone patients are considered disabled and thus protected by the ADA. Now I
realize that many do not like the idea of being disabled, however when one considers
the prejudice directed towards methadone patients because of our disorder, our primary
disability has become the stigma we endure. And that is a good reason for the ADA
to protect us!
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