Methadone Today
Volume III, Issue IX (September 1998)
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Letter from the Editor
TIP/TAP Series: Treating Pregnant MMT Patients
- Nancy Rose (DONT Secretary)
Medical Maintenance - The Holy Grail &
the Con Man - Bao Dai
NAMA Column #6 - Joycelyn Woods
Doctor's Column
- Naltrexone-Related Deaths
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TIP/TAP Series: Treating
Pregnant MMT Patients
Nancy Rose (DONT Secretary)
As previously mentioned, the TIP/TAP series of books are put out
by the U.S. Department of Health and Human Services. Much of the
following information is from TIP 2, Pregnant, Substance-Using Women.
All emphasis is mine unless otherwise stated.
TIP 2 states, "Methadone substitution is the standard treatment
for heroin addiction. Methadone treatment alternatives consist of
(1) high-dose blockade, (2) low-dose maintenance, and (3) medical withdrawal.
Medical withdrawal of the woman is NOT recommended in pregnancy because
of the increased risk to the fetus of intrauterine death" (p. 19).
Page 20 warns: "NARCAN (or any narcotic antagonist) should NEVER be given
to a pregnant, substance-using woman except as a last resort to reverse
severe narcotic overdose."
"Methadone maintenance is strongly encouraged for all pregnant,
opioid-dependent women. It provides the following advantages:
-
Reduces illegal opioid use as well as use of other drugs.
-
Prevents fluctuations of the maternal drug level that may occur throughout
the day.
-
Improves maternal nutrition, increasing the weight of the newborn.
-
Improves the woman's ability to participate in prenatal care. . . to prepare
for the birth. . . and begin homemaking.
-
Reduces obstetrical complications" (p. 20).
Regarding dose: "In general, the clinical trend is toward use
of an individually determined, most effective dose that is adequate to
prevent withdrawal symptoms. . . [and reduce]. . . drug hunger. . . . Based
on current and emerging research, the National Institute on Drug Abuse
suggests that maintenance doses below 60 mg are NOT effective and hence
not appropriate. Arbitrary low-dose policies for pregnant and nonpregnant
patients is often associated with increased [illicit] drug use as well
as reduced program retention" (p. 20).
Additionally, "An increased methadone dosage may be needed in
later stages of pregnancy to prevent withdrawal (The greater plasma
volume and renal blood flow of pregnancy can contribute to a reduced level
of methadone in the blood)" (p. 20). TIP 1, State Methadone Treatment
Guidelines, also covers MMT in pregnancy, stating (emphasis theirs): "It
is extremely important to understand the increases in blood volume and
metabolic changes specific to pregnancy, as methadone-maintained women
frequently develop increasing signs and symptoms of withdrawal as pregnancy
progresses and need elevations of their oral dose in order to maintain
the same plasma level and remain withdrawal free" (page 87). TIP
1 states that even women on high doses prior to becoming pregnant should
not be forced into withdrawal, as "withdrawal is not recommended during
gestation, since the risks of withdrawal and recidivism associated with
withdrawal are HIGHER than any that might theoretically be associated with
a high dose of a licit medication such as methadone" (page 87).
TAP 7, Treatment of Opiate Addiction with Methadone: A Counselor
Manual says, "Pregnant users who are in treatment with methadone deliver
healthy babies. It is true that babies born to women on methadone
sometimes experience some withdrawal symptoms. . . [but] symptoms are routinely
treated by the baby's pediatrician and do not result in any long-term damage.
. . . The most important comparison, however, is not how these babies compare
with nonaddicted [babies] but rather how they compare with babies of mothers
addicted to heroin. Studies have demonstrated tremendous benefits from
methadone" (p. 6).
During labor and delivery, physicians are advised to "Provide
pain management as appropriate. Analgesia and anesthesia administered
during labor may include the same range of options available to all patients.
Pain medication and attempts at adequate pain relief should NEVER be withheld
simply because the patient has a history of alcohol and other drug use...Due
to tolerance, patients may require higher than usual doses of short-acting
intramuscular/injection narcotics. . ." (TIP 2, p. 39).
For postpartum care, health care workers are advised to "Encourage
continuation of. . . drug treatment" (TIP 2, p. 42). Also, "Permit
breast feeding in methadone-maintained women. . . Breast feeding is NOT
contraindicated in a methadone-maintained patient if she is known to be
free of other drug use and is known to be HIV-seronegative" (TIP 2, p.
42).
There is much more information about treating pregnant MMT women,
but it is beyond the scope of this article. If interested, order
a set of TIP/TAP books (or at least TIP 2, Pregnant, Substance-Using Women)
by calling (800) SAY-NOTO (729-6686).
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Medical Maintenance: The Holy Grail--&
THE CON MAN
by Bao Dai
"Medical Maintenance": the Holy Grail of most methadone maintenance patients...
that thing which would allow stable MMT patients to be more or less treated
like anyone else with a chronic medical condition requiring daily medication.
No more frequent trips so someone can watch you drink from a paper cup.
No more lining up at dawn. No more nagging fears that something just
might go wrong and your clinic routine will be delayed for hours or you'll
arrive to find the door locked, or you'll piss the wrong person off and
end up with a quick detox/ticket back to active addiction from which you
might never ever return.
There have been "experiments" involving .1% or less of MMT patients
which have been conducted (primarily at Beth Israel in New York City) literally
for years, but recently there has been a growing cry coming not only from
patients but from the public health sector and even the Drug Czar to radically
change the face of the Methadone Bureaucracy to make it more patient friendly
and accessible to those who could benefit from it.
The availability of "Medical Maintenance" - primarily for
patients who do not have active drug abuse issues or other problems which
might require more frequent clinic contact - is one of the things which
would change the present system. To that end, the State of Connecticut
enacted a law allowing for the establishment of programs which would allow
selected patients to pick up a 30 day supply of methadone at a time.
The law will apparently go into effect sometime later this year.
In 1997 a person calling himself "Laurence Alderman, M.D."* began
posting on an Internet "mailing list" devoted to the discussion of methadone
treatment. An "Internet Mailing List" is essentially a free system by which
subscribers send communications to a single address which is then distributed
to all subscribers. The "Methadone List" was subscribed to mainly
by patients, although a handful of providers have also been an active part
of it (notably Dr. Marc Shinderman of the Center for Addictive Problems
in Chicago).
"Larry, as he became known, participated in the List intermittently
(frequently unsubscribing after people attacked him for holding such views
as "all patients are cons") claimed to have been a methadone patient himself
while in medical school and also claimed he owned a clinic in New
Haven. When the law passed, Larry's clinic soon included the "only (seriously
operating) medical maintenance program outside of New York City"
for a lucky three hundred. Dr. Shinderman and a host of patients
took him at face value.
And why not believe him? It isn't as if MMT patients are
known for holding doctors in terribly high regard, and Larry's general
attitude toward patients was fairly apparent from the start (e.g. his subjecting
patients with take homes to random demands that they return to the clinic
with their bottles to demonstrate none had been diverted) and it didn't
exactly illicit general affection for the man, or benefit the general
reputation of providers. It wasn't like saying "I own a clinic" was
going to make him Joe Popular.
To patients, the existence of an increase in the number of
Medical Maintenance programs anywhere in the United States is akin to proof
that there really is a heaven in the sense such programs are tangible illustrations
that maybe, just maybe, if you play your cards right in a few years you
won't *still* have to arrange your life so that you can spend a minute
(or as long as the staff wants) each day, or at least each week, at the
clinic.
Well, as things turned out, Larry, who had the habit of
popping up elsewhere on the World Wide Web like some sort of bad cyber
penny, allegedly doing all sorts of dastardly deeds which aren't here relevant,
wasn't a doctor and never had anything to do with a clinic (except perhaps
as a patient of a counselor who had a very short career).
Still, Larry could be having whatever fun he was having pretending
to a bunch of recovering addicts that he was one of their own who was,
so to speak, giving back to the community by operating a clinic and championing
Medical Maintenance like some brave pioneer, except he got greedy.
Now, this greed had nothing to do with money--like a drooling
pedophile, Larry needed a victim of flesh and blood, and he found one in
the person of "Nancy," a nurse who had recently left New Hampshire
because she left her husband who had relapsed into active heroin addiction.**
Nancy moved to Massachusetts to live near her daughter and grandchildren.
She enrolled in the only viable clinic for her; one which might have been
called "The Eighth Circle of Hell" if its owners had a sense of humor,
but they had no sense, let alone humor. The clinic didn't "recognize"
her documented years of clean tox screens--it made her start earning take
homes from scratch. And, of course, to earn a take home, a patient
had to be employed, and to earn a take home (indeed, not to be threatened
with a detox), a patient had to attend group therapy and other counseling
sessions. And, of course, the clinic held such sessions during regular
business hours. And so, of course, Nancy could not very easily hold
onto her job if she was to get the counseling the clinic felt she needed
to stop taking the drugs she hadn't taken for over five years (if you suspect
that perhaps the clinic may have gotten more money if patients didn't get
take homes and even more if they were unemployed, STOP BEING PARANOID!).
Larry hears of Nancy's woes and, like a blood-starved vampire,
descended upon her with promises that she could get on his Medical Maintenance
program just as soon as a spot opened up. . .she was always next on the
waiting list, and there was going to be a spot open soon.
By making such promises, Larry encouraged and got Nancy to release
all of her medical records to him. Perhaps this bit of voyeurism
is what got Larry off--a third-rate scam around the laws which protect
individuals' privacy--a mental and emotional kind of rape--it can only
be speculated, since Larry isn't talking (he has been asked to give his
side many times and has refused comment).
Not only that, but he had Nancy a bus ticket away from relapse.
Driven to the brink of insanity by her clinic's 7-day dosing regime, missed
group therapy sessions, and threats of discharge, Larry became Nancy's
only hope, as can be seen by their correspondence and her telephone bill.
But there were always problems. . .The State of Connecticut wasn't
sure the precious slot should go to a nonresident. There was this
problem and that problem. She was often packed and ready to go when
Larry would call to say "Sorry, but. . ." Much like that junky "friend"
you may have had who took your money to score on Tuesday but never showed
after you waited and waited, there was always some excuse. . .
. . . and Larry managed to string Nancy along for about half a
year. . . . Finally, things at her clinic got so Nancy couldn't take it
anymore. She was packed and ready to leave--even if it meant accepting
his offer to be a patient on his regular program for however long it took
to get on the Medical Maintenance program--even if she had to accept his
offer to live at his house and work as a secretary in his clinic for a
month.
Larry may have sensed the hounds of suspicion sniffing his trail.
Nancy wasn't too happy about being continually put off and was making sounds
like she might just call the State of Connecticut herself to learn the
nature of their alleged objections
.
As she was about to call and say her goodbyes, hoping she'd be
back in a month, Nancy got the following E-mail from Larry:
Subject: Ok. . . you didn't call AGAIN. . .! [suggests he's replying
to a letter wherein she complained about how he was stringing her along].
"I was just sitting down to write you and I got your message.
I had a meeting yesterday morning w/ H & as and there is no more Med
Maint in the State of Ct. I got so pissed off I handed over the clinic
to my partner and new TOTAL owner of both clinics this afternoon. They
met w/ me and then jerked me around for a day, then @ 4 pm today I got
this wonderful news. They say it's because of the suit the FDA has
pending against them for unilaterally putting in Med Maint w/o Federal
perm. It def. has nothing to do w/ you as all med. Maint patients lose
their once a month p/ups as of Mon. March 16. I have had enough and
am very sorry this had to happen to you also. Your best bet at this juncture
is to go back to the other clinic you were on up there before ["The Eighth
Circle of Hell"]; now that winter is over you won't have Rt 128 to contend
w/ anymore.
"I'm done w/ Methadone Maint., no money, too many problems, too
many lies, including the state and fed officials. This has dragged on so
long now I feel obligated in some way to you. However there is nothing
I can do. Please accept my apologies and I wish you the best of luck in
this absurd system. Your Friend always, Larry."
Who wants a long-term house guest who is expecting there to be
a job waiting for her at a clinic, especially when the clinic doesn't exist?
It could have proven a rather tense situation.
"So what?' you ask. "I have to drive 90 minutes 7 or 6 or
5 or 4 or 3 or 2 or at least one time a week."
Well, some little psycho doesn't have your entire medical and
social history with which to blackmail you or post on the Internet or use
for masturbatory purposes. You didn't almost quit your clinic and
head off to end up puking your guts out all over some sleazy motel room
and then go out and find a fix and a point just to be in some form of human
condition in which you could figure out exactly what the point of it all
could have been. No one played upon your desperation just to have
a good time.
The point is that under the present Methadone Bureaucracy, we
are all desperate people. They call narcotic addiction a disease,
but they refuse, by and large, through regulations and rules on reams of
paper made from the trees which have died for our "sins", to treat a very
treatable condition as a simple medical one, requiring that patients maintain,
if only to humble themselves before the Bureaucracy and some Providers,
just a touch of that certain something which differentiates an addict from
someone who needs a drug to simply function normally, perhaps to punish
patients, as the average methadone clinic seems part penal in inspiration.
It isn't good form to exploit anyone, especially not the already
exploited by playing on their hopes and dreams and need to believe.
And exploitation for its own sake is sick--it's a sickness which is chronic,
and I'd bet my last dollar that this person who called himself Laurence
D. Alderman, M.D. pulled the wings off flies as a youngster, stuck firecrackers
in the orifices of small pets as a teenager, and hides bed pans at hospices
in his spare time will show up somewhere, someplace, pulling another stupid,
pointless, yet terribly cruel hoax. . .
. . . perhaps in prison--as several sources indicate that authorities
and Yale University, with which he claimed affiliation, are interested
in his fraudulent misrepresentations. Well, at least in prison, I
understand justice for such things is terribly swift--if a tad harsh and
lacking in due process.
---
*It's uncertain, but a review of governmental records resulted in the
conclusion that this was "probably not his real name" - there clearly is
no physician in Connecticut involved in MMT or affiliated with Yale University
with that name.
**While NH allows no clinics within its pristine borders and, thus,
Nancy had to regularly skid through the pre-dawn snow to get to a clinic
in another state to maintain her recovery, it obviously must have heroin,
but that's another story.
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NAMA Column Number 6
Joycelyn Woods
This past month, New York City's Mayor Guiliani said that he was
going to close all methadone programs. The Mayor has absolutely
no authority over methadone programs in New York City; they are all state
licensed and funded. The only program that Mayor Guiliani might be
able to do anything to is the KEEP Program at Riker's Island because it
is a city jail. For the Mayor to attempt to close it, he must order
a needs report. The report would clearly confirm the need for the
KEEP Program which is known around the world as the first jail-based methadone
program.
The Mayor could harass methadone programs through the things over
which he does have control. The primary strategy that he has used
in the past, and will probably continue to use, is Medicaid. During
the past two years, methadone patients have been assigned to workfare programs.
Another problematic area is toxicology reports. The later
is a breach of confidentiality; however, over the past two years, Medicaid
has been requiring toxicology reports with the insistence that they are
not going to use them for anything. Then why request them?
NAMA has believed that from the beginning this has been a way to get at
the most vulnerable patients in methadone treatment and that eventually
toxicology reports will be used against patients. So far they have
not.
The Mayor's remarks have had a positive impact. The reality
is that it was a bizarre thing for the Mayor to say from the city with
one of the largest addict populations in the world and also a significant
HIV prevalence rate. His words were so far out on a limb that even
policy makers who do not normally defend methadone found themselves doing
so. All the major agencies, institutions, organizations and societies
have made statements defending methadone treatment.
The most important message comes from the patients, many of whom
wrote handwritten notes to the Mayor saying that methadone has saved their
lives and that without it, they most certainly would be either dead or
a drain on society. The letter writing campaign to the Mayor continues,
and I would estimate that several thousand letters have already been received
from all over the United States and continue to be sent.
If you do not live in New York City, do not think this has nothing
to do with you. Other mayors and governors, encouraged by New York
City's Mayor's comments, could get a similar idea. These elected
officials could have control over methadone treatment. In essence,
this has been a warning that we need to organize more and develop connections.
But most importantly, we need to educate the public and our elected officials
that methadone does work.
Here is what you can do as a patient:
Write a letter to Mayor Guiliani; handwritten ones are fine.
Send it to: Mayor Rudolph W. Guiliani, City Hall,
New York, NY 10007
NAMA needs copies of your letter so that we can show several
federal agencies, including General McCaffery of the Office of National
Drug Control Policy and Donna Shalala of Health and Human Services how
the Mayor's callous remarks have impacted the lives of patients.
NAMA is working with a committee of organizations to make sure
that your letters will make the greatest impact. We need to have
an idea as to the number of letters that have been sent to the Mayor's
office to show that methadone patients are concerned. Send
a copy of your letter to: National Alliance of Methadone Advocates,
435 Second Avenue, New York, NY 10010 Attn.: Letter to NYC Mayor
Project
Organizational News
This month, we welcome three new chapters:
NAMA of Northern California (NAMA NorCal), Khalil Abdus-Samad
P.O. Box 425264, San Francisco, CA 94112
Haverhill Associated Methadone Advocates (HAMA), Daniel LaProva
P.O. Box 1471, Haverhill, MA 01830
Minnesota Chapter of NAMA (MN NAMA), Becky Duarte
Hennepin County Treatment Program, 1800 Chicago, Minneapolis
MN 55404
The National Letter Writing Campaign
This month's letter goes to General Barry McCaffery, Director of
the Office of National Drug Control Policy (ONDCP). McCaffery has
been supportive of methadone maintenance treatment and has appointed a
person within his office to promote it. McCaffery advocates for expansion
and accessibility of methadone maintenance treatment. He has been
supportive of physicians prescribing methadone as one of the strategies
to expand treatment and make methadone available. So why write to
him, you may wonder? The ONDCP is part of the Executive Branch of
government, and no one has better access to the President than McCaffery.
By writing to him, we are giving him ammunition to use to make methadone
treatment more accessible and "more consumer oriented."
I can not emphasize the importance of this letter writing campaign.
If we want to change methadone treatment, it is imperative that we become
habitual letter writers. Methadone treatment has been over regulated
and politicized, and if we are to ever rid ourselves of this serfdom, we
must become sophisticated medical consumers. Finally, if we are to
grow in numbers, each of us must undertake to recruit at least one other
patient.
Patient issues have already become realized as important aspects
of methadone treatment, and patients need to be involved in policy making.
This has occurred because of NAMA and other groups and individuals who
have come to realize that something is wrong with methadone maintenance
treatment. This is the first step in really changing it to the caring program
that Drs. Dole and Nyswander envisioned when they developed methadone treatment.
It is our responsibility to ensure that methadone maintenance
treatment lives up to the covenant that it once promised. No one
will do it for us. 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 web site (www.methadone.org) where
you can find information and links to our chapters and other important
methadone web sites.
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