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Methadone Today


Methadone Today

Questions? Comments? Speak out: yourtype@tir.com Order Newsletter in print: Order here
 
Volume III, Issue VIII (August 1998)

TIP/TAP Series:  Urine Testing/Dirty Urines - Nancy Rose (DONT Secretary)

Americans With Disabilities Act Applies to Prisons/Jails - Robin Robinette (TMAC)
 
My Takehomes and A Negligent Program - Name withheld by request

Letter from the Editor - Beth Francisco

NAMA Column #5 - Joycelyn Woods

Doctor's Column - Patient wants to know what to tell a prospective employer.

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TIP/TAP Series: Urine Testing/Dirty Urines
Nancy Rose (DONT Secretary)
 The TIP/TAP series is put out by the U.S. Department of Health and Human Services, Center for Substance Abuse Treatment (CSAT), intended for the nation's substance abuse treatment programs. In the "Foreword" of at least several of the books (TIPs 1, 2, 19, 20, and others), there is a personal note from the Director of CSAT.

 TIP 1, for example, states that CSAT, along with the American Methadone Treatment Association and the American Society of Addiction Medicine's Committee on Methadone Treatment, have "developed these practical treatment guidelines. . .[to] serve as a blueprint for state policy officials and methadone maintenance treatment providers."  The CSAT Director goes on to say, ". . . this nation's [MMT] programs must incorporate what the scientific community has demonstrated to be effective treatment practices.... based on lessons learned from relevant science-based research."

 TIP 1, "State Methadone Treatment Guidelines," has an entire chapter (Ch. 6) on "Urinalysis as a Clinical Tool" (p.  59).  It says, "Methadone maintenance programs should offer treatment. . .where a sense of trust and safety exists....If a patient must provide a urine specimen in an atmosphere that suggests punishment and power, trust and patient growth cannot thrive.  There is an inevitable tension that exists [when] programs...use urine screening...in conferring take-home privileges....Falsification [of urines] is best minimized if patients do not feel that the urine results will be used to punish them" (p.  61).

 "Some patients will adamantly deny substance use despite positive results... .[MMT] providers should take adamant denial seriously and not discount the patient as a manipulator or a liar....Whenever possible, the positive screen...should be retested and confirmed by another method" (p. 62). Clinic staff should consider the patient's history and previous urine results when deciding whether or not to believe the patient.

 TAP 7, "Treatment of Opiate Addiction with Methadone, A Counselor Manual", says testing can help counselors determine whether a patient is diverting his/her methadone or taking illicit drugs but need to understand that there can be errors in test results.  Occasionally, a test will show "low specific gravity" which means the urine is "watery."  TAP 7 states, "This can indicate that the patient had drunk a lot of fluid just prior to the urine test OR that the specimen was diluted with water.  Eating poppy seeds, even as little as a teaspoon, can result in a morphine-positive test" (p. 26). Counselors, as well as patients, should be aware of medications, including over-the-counter and other substances that may possibly affect urine test results.  This topic was covered in a previous issue of Methadone Today (Vol. II, no. 6, June 1997).

 Counselors are advised of various ways to approach the patient regarding positive--"dirty"--urine test results. "Punishment" such as lowering methadone dose or discharging from the program are NOT advised. TIP 10, "Assessment and Treatment of Cocaine-Abusing Methadone-Maintained Patients" states, "It is clinically appropriate to treat patients with concurrent dependencies within methadone programs. . . .Lowering methadone doses as part of a contingency management protocol [for urine tests showing cocaine] does NOT appear to be effective in managing cocaine use and may increase heroin use" (p. 2).

 Regarding retention in the program versus discharge for "dirty" urines, TIP 10 "agrees that patients should be given every chance to continue in and try to benefit from treatment...Staff should make every effort to rework treatment plans and provide help and counseling for continued use of other drugs.  A policy of administrative discharge. . .for continued addict behavior [i.e., dirty urines], may sometimes be self-defeating.

 If a patient continues to use heroin, the physician should look carefully at dosage and blood plasma levels to see if there is a problem with metabolism [or] absorption. . .that might influence adequacy of dosage" (p. 55) to see whether an increase in dose may help.  As TAP 7, p. 5, states, "Methadone is not a treatment for cocaine...or alcoholism....[but] the majority of patients on methadone substantially reduce their overall use of drugs and alcohol."

 TIP 10, pages 55 & 56 state, "There will, nevertheless, be situations when an administrative or disciplinary discharge is necessary" such as when a patient is violent toward staff or other patients or for "criminal behavior", or when a private clinic has to discharge for nonpayment.  BUT, they recommend an "ethical criteria for withdrawal from methadone and a readmit procedure...",  and they say "blind withdrawal is unethical unless requested by the patient.

 Withdrawal [or] discharge should be a LAST RESORT in light of the strong probability of relapse and the subsequent dangers of infectious disease that jeopardize the patient's health..."Additionally, regarding pregnant patients, "It is...essential to retain pregnant patients in treatment where they may benefit from supportive and medical services."

 
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ADA Applies to Prisons and Jails
by Robin Robinette
Tennessee Methadone Advocates Coalition (TMAC)
 
  Methadone patients have been discriminated against in countless ways, but a new Supreme Court ruling may clear the way to end the horrific practices of so many prisons and jails across the country who refuse to medicate patients who may be detained or incarcerated.  The following information is summarized from a press release dated June 15, 1998 at the American Civil Liberties Union website (http://www.aclu.org/news/n061598b.html) and from the contained links which post the "Friends of the Court" brief.

 The Supreme Court ruled unanimously that the Americans with Disabilities Act (ADA) applies to prisons and jails. The issue in the case that was heard related to a prisoner request for assignment to boot camp to reduce his sentence but was refused because he had high blood pressure.  Pennsylvania (and 36 other states) had claimed that prisons were outside the requirements of the ADA, but the justices confirmed that they are a "public entity" and that any programs or services must comply.  Some of the references included (directly quoted from the brief):

 "Disabled prisoners have a right, if the [ADA] is given its natural meaning, not to be treated even worse than those more fortunate [able-bodied] inmates."  Crawford v. Indiana Department of Corrections, 115 F.3d 481, 486 (7th Cir. 1997) (Posner, C.J.).   Seeking equal access, not better treatment than others, disabled prisoners have raised substantial claims of discriminatory treatment in seeking relief under the Rehabilitation Act and the ADA."

  •   ". . . Congress has stated that the non-discrimination mandate of the ADA applies to all operations of state and local governments, has authorized the Department of Justice to promulgate regulations that specifically apply the statute to state prisons, and then has actually incorporated these regulations into the ADA. "
  • "A public entity shall make reasonable modifications in policies, practices, or procedures when the modifications are necessary to avoid discrimination on the basis of disability, unless the public entity can demonstrate that making the modifications would fundamentally alter the nature of the service, program, or activity.   28 C.F.R. 35.130(b)(7)
  • ". . . also 36 C.F.R. 1191.2 (1997) at 12.1 (applying the ADA to "jails, holding cells in police stations, prisons, juvenile detention centers, reformatories, and other institutional occupancies where occupants are under some degree of restraint or restriction for security reasons").
 It must be remembered that the ADA will only apply to persons who are NOT USING ILLICIT DRUGS and that the disability one is seeking relief from discrimination for is opiate addiction, treated with prescribed methadone hydrochloride.  This has nothing to do with the Social Security Administration's removal of addiction as a disability eligible for coverage.

 Reasonable accommodation is required to be made, so be sure that any request will not present more of a problem than might be granted to another person needing a prescribed medication for a chronic illness. This might mean that your program would need to cooperate in some way.  Enlist the local or state chapter of the ACLU for assistance, as many systems may still refute the challenge, and time may be critical for many patients.  Advocates may want to write letters to ask for assistance BEFORE the issue arises, so that a response from ACLU could be "in hand" should it be needed. END
 

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My Take Homes and A Negligent Program
Name withheld by request

 I see the frustration and agony we face every day in our quest to be normal citizens.  A little true story that may drive the point home of how programs can control and affect our lives.  The program director in a certain state had promised me over the phone many weeks in advance of moving my family from New York to there that he would secure a once-a-week methadone pickup for me.  He did tell me a few times on the many calls that there should be no problem.

 With that verbal promise, I moved to Florida.  Mind you, I was getting twice-a-month take outs from the NYC clinic before I moved.   They were approved by federal, New York State and New York City authorities. It was well documented and in my file when I started on the new program.

 When I arrived for my first pick up, to my surprise, the program director had done nothing.  So, he called the State Methadone Agency (SMA) without any look at the facts or preparation for his conversation to see if they would approve a once-a-week pickup schedule.  The person on the other end of the phone either got up on the wrong side of the bed or did not get his the night before and denied all but a twice-a-week pickup.

 I then asked the Director about what he had told me and said that I was in deep trouble as I counted on him and his word.  I travel for work all the time at a moment's notice--like midnight the night before pickup day.

 So we were off to a bad start.  For the next few months, I had three counselors in three months; they were not helpful.  I arranged not to travel.  This did not give me good status at work.  The fourth counselor was able to help me secure emergency bottles to keep my job.

 Then she left, and I got the "counselor from hell."  She had a chippy all the time.  I needed the emergency takeouts almost every week now.  By the way, I substantiated my travel in triplicate, so there was no doubt where I was and for what purpose.  However, she started to question me and said that the doctor could get in trouble for all the special takeouts I needed.

 The new director, who was married, and my counselor were caught in the car around back of the clinic doing their nasty deed.  Well, they decided to try and get me a special exemption to allow me six  take outs at a time again.  The dynamic duo decided I knew too much and only got me five bottles at a time, which still made me come to the clinic two times a week.  It was easier for them to get me an exemption than ask the doctor for the special take outs.  State law usually allows as many bottles as needed up to two weeks at a time or more, depending upon the situation as long as it can be substantiated.  I had checked this out before I went on the Florida program.

 The company I was employed with spun off from the main company, and I had only a company name change on the check (we have to substantiate employment every month).  On a Sunday, with my plans to travel to Atlanta in my pocket, the counselor from hell and her director lover said that the Special Exemption was no longer good and took my bottles.   I pleaded to show that this was not true and that only the name changed, not the company.  The same person signed the check, my employee number was the same, and all my other information did not change.  Their decision was that I had to pick up two times a week.

 Again, I had to put my job in jeopardy because of not being able to travel and meet my promised job responsibility.  So I got a letter from my boss after telling him another story as to why I needed it. This was the third letter I had asked for.  They lost the first, and I had to get another one as the date needed to be different by the time they procrastinated.  I asked every other pickup day as to the status of the request and was told a lie by the duo.  This added great amounts of stress, and I almost lost my job, as I had no way of arranging a guest pickup at another clinic due to not having advanced warning and notification most of the time.

 So I had to do what was necessary to cope (if you get my drift).  I tried very hard not to relapse, but that even came close after 20 plus years of being clean.  I have been stalled in airports, and bad weather interrupted my being able to return on time on many occasions.

 So, finally, I called the Senior VP of all the clinics, and he was appalled at their behavior, plus the fact I had spoken to the head of the State Methadone Authority to try and see if I could get a sane resolution to this matter.  The SMA Director called the senior VP of the clinics.   The end was at hand for the duo, as they were both fired for immoral behavior and endangering my safety, health, anonymity, and well being.  Their negligent behavior and lack of judgment was negatively affecting many other patients as well.   Many a warning and threat was issued to the clinic; the DEA, FDA, and other state authorities were after them, and the clinic was threatened with closure.

 That is when I was assigned a new counselor (The angel Head Nurse) for many apparent reasons, and my health was not good (Hep C and Cirrhosis).  She had a special meeting with the State Methadone Administrator as he has the authority to grant special exemptions.  She drove all the way to the state capitol to meet with him, as face to face is the best way, and she secured a once-a-week take home exemption for me which is still in force.

 Note: Old "counselor from hell" had added many incorrect lies to my file which I did not know about, and it was signed by both the old counselor and director.  I had that stricken from the file and corrected.
 
 The moral is that sometimes counselors and directors make up restrictions on the fly.  You need to know what your rights are and how you can protect yourself from this happening.  If I had this information either at the clinic or on hand, I would have been much wiser.  A knowledgeable patient is a wise patient.  Information rules. This is one of the reasons that others in our position need to have availability to the real truth and not a made up set of rules that change to meet the counselor's or clinic's needs.  Our right to anonymity and safety of our health is not to be compromised.

 This is a true story, and it could have been avoided by having the information nearby and being told the truth by people who (in some cases) are out only out to burn certain people.   We are entitled to be treated like human beings and not subjected to endangering our health and well being by a bad counselor whose ambition for power over you can affect you to your very human core.
 
 Regards, and I hope some others will learn by the injustice done to me by the people who run our daily lives.
 

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 From the Editor

Beth Francisco
 This is the third anniversary of the newsletter.  As a direct result of Methadone Today and/or DONT patient advocates:
  •   a doctor in a hospital emergency room raised an MMT heart attack patient's dose of pain medication
  •   many patients are being properly dosed after suffering low-dose policies
  •   an abstinence-oriented treatment center allows methadone patients to go through their program and remain in their MMT program
  •   several city Health Departments have ordered subscriptions
  •   patients have been informed about their rights and to file "901" Recipient Rights Complaint forms if they feel their rights have been violated
  •   patients are able to read something positive about their treatment and do so each month.
  •   patients have been helped to understand the Rapid Detox procedure
  •   methadone myths are being destroyed and stigma surrounding MMT has been diminished.
  •   patients have learned they are covered by the Americans With Disability Act (ADA) against job discrimination (also in jail/prison).
  •   individual patients have been helped with numerous problems resulting from their status as methadone patients.
  •    and more. . . . .
So, the word is getting out, and we are making a difference.

Funding

 The Drug Policy Foundation (DPF) turned down our last grant proposal.  However, they have set aside a six-month technical assistance grant to help us make the transition from dependency to becoming more independent.

Don't you get money from NAMA?

 No, each chapter is a separate entity, although we work toward the same goals.

What does this mean to me?

 It means that those of you who have been receiving Methadone Today for the last few years but have not sent a donation need to think about what the newsletter has done for you and other MMT patients.  Then, you need to send a donation.  The grant was not meant to give a free ride for those who work and are able to pay.  So, we have to start doing more and more for ourselves, because the DPF will be doing less and less for us.

 Some of you know that DONT/Methadone Today helps patients to figure out where to go with problems and to get help.  We will still do this, but patients must pay expenses such as phone calls, photocopying, and postage.  If you need literature, this also applies.

Do you get paid for the work you do on the newsletter?

 Neither the editor nor advocates get paid for the work they do.

Why should I subscribe?

 If you enjoy reading Methadone Today and learning about your rights and your treatment, then you should contribute, at least monetarily, to DONT to help offset the cost.  Not contributing is continuing with one's addictive behavior--living off others, letting others do it, and just taking advantage.
 
 Patients and staff should have a sense of pride in Methadone Today.  The newsletter is distributed extensively in the city of Detroit and surrounding area.  We also have subscribers from most of the states in the US, and we even distribute to other countries.

I guess you pay for printing and postage with subscription money, but what will you do with the donations?

 Donations will be used to maintain the web site which has ALL BACK ISSUES, plus an index by subject that leads people right to the issues they need on subjects in which they are interested.   Donations will help us pay for the other expenses we incur sending the newsletter and other literature to policy makers, medical personnel (remember the doctor who dosed the MMT patient properly), clinic staff, and the general public.
 
 How would you feel if you asked us for help, but we couldn't help you because we could not afford to make the phone call to the jail to try to get you dosed or we could not send literature to your clinic which would tell them about split dosing, serum levels and adequate doses, etc?

What can I do?

 First, you can donate and/or subscribe to the newsletter (use coupon below please).  One possible suggestion for those patients who are receiving complimentary copies at their clinic: perhaps you can ask your clinic administrators to order a clinic subscription that they can pass out to  patients.  This would relieve us of a large burden.  Or, ask your clinic if you can put a canister in the clinic for patients to drop change in when they take a newsletter (please okay this with DONT as well as your clinic).

 If you know of anyplace we may be able to get funding for the newsletter, please let us know as soon as possible.  Or, if you have done well since becoming a MMT patient, perhaps you could make us your favorite charity!

 From the letters I have received, I know that you realize how important Methadone Today is, and hopefully, you can afford $12 per year to subscribe to the newsletter to find out about methadone maintenance treatment (MMT) issues, such as federal, state, and local regulations; information about diseases such as HIV/AIDS and Hepatitis C; treatments such as UROD/RAAD (Rapid Detox), LAAM, Ibogaine, and Buprenorphine, etc.; the U.S. Department of Health and Human Services' guidelines and protocols through the TIP/TAP series, which included but was not limited to proper dosing, serum levels, and length of treatment; treating pain and hospitalization; treatment of MMT patients in jail/prison; treating pregnant patients with methadone; issues regarding legislation that affect MMT patients; the fight for medical maintenance for long-time patients, etc.  These are very important issues for the MMT patient, but often the patient is not informed about his or her treatment and the issues surrounding it.

 We can also use your help in ways other than financial.  Pick an area related to methadone maintenance that interests you and needs correction, and help us out.  There is so much to do and too few people to do it.   No one will do it for us.

To donate or subscribe, please use form below:
If you want to help out, call us at:
Methadone Today/DONT     (810) 658-9064
or E-mail us at:  yourtype@tir.com
See snail mail address below

  •  I would like a single-copy patient/individual subscription to Methadone Today at $12 per year for 12 issues.
  •  I would like a single-copy clinic/institution subscription to Methadone Today ($25 - 12 issues/yr -- this entitles you to reprint rights).
  •  Please send a clinic subscription ($250/yr. - 100 copies/month).
  •  I would like back issues of Methadone Today ($10 - Vol. I; $10 - Vol. II; or $20 - Vol. I, II, and III to date).
  •  Here is a donation in the amount of $                  to help you send Methadone Today to someone who cannot afford it.
  • Enclosed are              32-cent (or other) stamps to help with postage.
  • I would like to donate $                  to the Methadone Today web site*.
  •  Please send personalized, laminated methadone MEDIC ALERT card (send your name, your clinic's name and clinic's phone number) - $3 with any order.
 Name                                                                                     
 Address                                                                                  
 City/State/Zip                                                                          

Please make checks payable to: DONT/Methadone Today and send  to  PO Box 164, Davison, MI 48423-0164Phone:  (810) 658-9064  Visit our web site* at http://www.tir.com/~yourtype
 

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NAMA Column Number 5
Joycelyn Woods
 
   No methadone advocacy groups were funded by the Drug Policy Foundation (DPF) during the Spring round.  This includes Methadone Today/DONT in Detroit, Wisconsin NAMA, Chicago NAMA, The MAG of Indiana and NAMA itself.  This does not mean that methadone advocacy is being abandoned by the DPF, but we will have to tighten our belts.

  As a network, we are going to have to reevaluate how we operate and particularly how to support the work of advocacy groups.  NAMA is already planning to meet with our chapters during the National Methadone Conference and a few weeks later at the Harm Reduction Conference in Cleveland.  It will only cost about $200,000 to fund NAMA and all of our affiliates, and in the scheme of things, that is not much.

  One thing is certain--we cannot depend upon one source for funding.  While the DPF helped to "jump start" NAMA and our growth, we have to consider our options.  Because of the stigma we have to overcome, it will have to be a creative solution.  These next years will be a transition to more stability, and we are not going to go away.  All of NAMA's chapters are in it for the long haul.

     We welcome our first chapter in Texas--TEXNAMA.  The group is being sponsored by one of our Advisors, Dr. Tom Payte, of Drug Dependence Associates.  John and Barbara Fingers are the organizers of TEXNAMA, which they intend to expand statewide.

    Positive Health Project, the sponsor of one of NAMA's chapters, the Midtown Methadone and Advocacy Group, will be the first needle exchange program to put public ads in New York's subway system.  At a press conference held in Times Square early in July, Jason Farrell announced that throughout July, 1140 ads will appear in subway cars to promote New York City's needle exchange programs.

   Appearing in the Journal of the American College of Physicians, is an editorial by Dr. Sox who criticizes the medical profession for their passive acceptance of our nation's drug policy and the treatment of addiction.   In particular, the editorial gives an excellent explanation of methadone maintenance and continues with:
 

 "Probably the most important action is to rethink our attitudes toward addiction to illicit drugs and to recognize it as a chronic disease rather than a manifestation of psychological impairment."   As one expert has said, "Drug use is a choice, addiction is not."  We need to open our minds to methadone maintenance, which is a pharmacologically sound approach to minimizing the harm from addiction." (Sox, H.C. The national war on drugs: Build clinics, not prisons  [President's Column] ACP Observer 1998, June).

International News

Over the July 4th weekend, the Steering Committee for the 1st Conference for the Repeal of Prohibition met.  Expected to attend are Francois Reusser and Judith Laws from DROLRG/Switzerland, Marco Cappato of TRP (Italy) and Andira E/Mordaunt of the Drug Users' Rights' Forum (UK).

Matthew Southwell of the Respect Users' Union London also contacted me this month to ask NAMA to be the North American representative for the International Users' Groups' Meeting which takes place during the International
Conference on Harm Reduction.
 

Meetings and Conferences

The First Methadone Advocacy Conference

Saturday, September 26, 1998 - 9:30 AM to 5 PM
The voice of the methadone patient has been excluded from methadone treatment for too long.  This conference will discuss the empowering of methadone patients, stigma and important issues that impact the lives of methadone patients, such as physician prescribing.
Place:  Roosevelt Hospital Auditorium; 1000 Tenth Avenue, NY City
Fee:  $25 or a methadone patient ID card and/or donation

Expanded Pharmacotherapies for the Treatment of Opiate Dependence

Friday, September 25, 1998 - 9 AM to 5 PM
Several countries are using opiates for maintenance treatment, including codeine, palfium, morphine, buprenorphine and injectable methadone.
Place:  New York Academy of Medicine
Fifth Avenue and 103 Street, New York City
Fee:  $40/50 (lunch included) $20 students

American Methadone Treatment Association Conference 1998

September 26-29, 1998
Access Change Challenge Opportunity
Place:  Marriott Marquis, New York City
Fee:  $360

Second National Harm Reduction Conference

October 7-10, 1998
During the conference will be the Methadone Consumer's Meeting sponsored by NAMA and MALTA.
Place:  Cleveland Convention Center, Cleveland, Ohio
Fee:  $300 (before 9/1); $350 (after 9/1)

The National Letter Writing Campaign

This month's letter goes to a local representative and it is your choice.  It can be the mayor or a council member that is important in deciding health issues.  I cannot emphasize the importance of this letter writing campaign.  We all need to become habitual letter writers if we want to change the methadone treatment system to a caring and patient-oriented program.

 No one will do it for us.   Very often, it is just not to their benefit.  And we can do it; we would not have methadone treatment at all today if it was not for the perseverance of a few dedicated professionals and the early patients who were facing far more difficult odds than we are today.  They started it, and we have to finish it.  You can start by writing this month, and don't forget to drop NAMA a short note telling us who you wrote to.  We are tracking all of this and will follow it up.  And don't forget to check our website (www.methadone.org) for any other information.

 National Alliance of Methadone Advocates
 435 Second Avenue
 New York, NY  10010
 Attn:  The National Letter Writing Campaign
 
 

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