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Methadone Today
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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."
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". . . 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. "
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"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)
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". . . 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:
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a doctor in a hospital emergency room raised an MMT heart attack
patient's dose of pain medication
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many patients are being properly dosed after suffering low-dose
policies
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an abstinence-oriented treatment center allows methadone patients
to go through their program and remain in their MMT program
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several city Health Departments have ordered subscriptions
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patients have been informed about their rights and to file "901"
Recipient Rights Complaint forms if they feel their rights have been violated
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patients are able to read something positive about their treatment
and do so each month.
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patients have been helped to understand the Rapid Detox procedure
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methadone myths are being destroyed and stigma surrounding MMT has
been diminished.
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patients have learned they are covered by the Americans With Disability
Act (ADA) against job discrimination (also in jail/prison).
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individual patients have been helped with numerous problems resulting
from their status as methadone patients.
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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
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I would like a single-copy patient/individual subscription to Methadone
Today at $12 per year for 12 issues.
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I would like a single-copy clinic/institution subscription to Methadone
Today ($25 - 12 issues/yr -- this entitles you to reprint rights).
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Please send a clinic subscription ($250/yr. - 100 copies/month).
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I would like back issues of Methadone Today ($10 -
Vol. I; $10 - Vol. II; or $20 - Vol. I, II, and III to date).
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Here is a donation in the amount of $
to help you send Methadone Today to someone who cannot
afford it.
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Enclosed are
32-cent (or other) stamps to help with postage.
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I would like to donate $
to the Methadone Today web site*.
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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 48423-0164. Phone:
(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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