A.T.F. Volume VI, #1. Winter, 1997, Page 2
Optimal
Methadone Dose?
CSAT: Medical Maintenance
From the Editor
Meetings to Note
Physician with a Mission
Survey: Managed Care and MMT
Addiction Treatment on the Internet
Feedback: Horrifying Attitudes
Patient Perspectives
Physician with a Mission
Henry Blansfield Physician With A Mission
Until he retired last September, Henry N. Blansfield, M.D. was a surgeon
and, later, a part time general practitioner in Danbury, Connecticut.
About 25 years ago he became interested in the social and political
aspects of addiction and served on the local alcoholism council. That
started him on his "mission." He frequently acts as an advocate
for persons suffering from addiction, which he stresses is a genuine
illness requiring rational and compassionate care. Such care, he believes,
is lacking in today's society.
A.T. FORUM: In what way is opioid addiction an illness, rather than
due to a person's character or upbringing?
DR. HENRY BLANSFIELD: As we've been able to explore the make-up of the
human nervous system it has become obvious that the compulsion to use
psychoactive chemicals is due to alterations in the neurotransmitter-receptor
apparatus between brain cells. Changes develop in the brain tissues
that explain drug craving, withdrawal, abstinence syndrome, and eventual
relapse that characterize opioid dependency.
A.T.F.: How does the abstinence syndrome come into play?
DR. BLANSFIELD: Following detoxification from heroin or other opioids,
the dependent person will usually develop depression, anxiety, and a
craving for the drug. These symptoms account for the high relapse rate,
somewhere around 85 to 90 percent. This also explains why persons detoxed
from methadone will return to street drugs or go back on methadone within
ten months (according to statistics supplied by the National Alliance
of Methadone Advocates).
I see that quite often, because my advocacy has been for people to go
on methadone and stay on it. If they get dismissed from a program usually
for some irrelevant infraction I try to get them re-established at another
clinic. Those patients can't live comfortably without methadone. Their
lives become dysphoric.
All my work in this field is pro bono. And I act as a physician only
in the sense of being able to identify when patients are sick and in
need of treatment. I don't treat addicts or prescribe opioid medications
for them. It has become known that I am available to help people find
the care that they need to deal with their addictions.
A.T.F.: Why do you believe methadone treatment isn't more readily
and easily available?
DR. BLANSFIELD: Society is unwilling to accept this method of treatment.
Many feel that methadone serves only to continue the addicted state,
substituting one drug with another. Abstinence is the goal, even though
treatment with methadone will return a person to a functional and comfortable
status in life.
This is very paradoxical to me. In medicine we don't seek absolute perfection;
but, rather functional and comfortable lives for our patients. If a
person has a leg amputated, we put on a prosthesis and help him go about
daily life. But with people suffering from relapsing opioid dependency,
many treatment programs don't do that. They try to change the addict's
basic nature, make the person toe the line, and try to change him into
a docile individual. This is how treatment programs are run, and the
slightest infraction of the rules can lead to dismissal.
A.T.F.: What's the situation in Connecticut where you've been most
active?
DR. BLANSFIELD: We have about 3,800 patients in methadone treatment,
but we need more than 20,000 treatment slots. The state claims there
is no waiting list, but that's untrue. The waiting list is in place,
but it's difficult for someone to get on it. There's no such thing as
an addict hitting bottom, desperately wanting to change his life, and
getting
right into methadone treatment it just doesn't exist.
There are currently 12 programs in this state, but that doesn't begin
to adequately serve the needs in the larger communities. Some patients
have to travel great distances to get to a clinic if they live in rural
areas.
I know of one patient who has cerebral palsy, recently broke his arm
too, and has a terrible time getting around. He's 15 miles away from
the nearest methadone clinic and just can't get there every day. What's
supposed to happen to him? He can get all the illicit drugs he wants
delivered right to his door, but methadone is unattainable for him.
In another case, the patient was unable to get to his clinic on time
during a snow storm one Friday due to an accident. Then he was refused
methadone dosing because he was late. So he had to go through a weekend
of withdrawal without any medication until Monday. That person's only
other alternative was to illicitly buy drugs on the street to tide him
over.
A.T.F.: That raises the issue of methadone diversion. What are your
thoughts on that?
DR. BLANSFIELD: The DEA harps on diversion, thinking that if there aren't
rigid safeguards surrounding methadone then these 'addicts' will sell
it and induce new users. But, we know that the addict seeking a high
doesn't like methadone because of the drug's slow and even metabolism.
So, those buying it on the street are mostly already established addicts
who want to avoid withdrawal; they're not first time drug users.
In my opinion, diversion isn't really germane to the issue of proper
treatment for opiate addicts. Many individuals I've advocated for wanted
nothing more than to get back into treatment and stop buying their drugs
on the street.
A.T.F.: Haven't you been very active in promoting medical methadone
maintenance? [Prescribing of methadone by primary care physicians on
a monthly or twice monthly basis.]
DR. BLANSFIELD: I introduced a medical maintenance resolution last year
that was passed by the Connecticut State Medical Society, and it went
on to the American Medical Association, which also passed it. But nothing
has been done because the DEA balks at the very thought of such an approach.
The claim is that the community physician wouldn't be trustworthy that
he'd use it as a way of selling drugs to addicts for personal gain and
this would only lead to more diversion on the streets.
A.T.F.: You've written about the concept of having successfully recovering
addicts share their experience, strength, and hope with young people
in schools and churches. Has anything come of that?
DR. BLANSFIELD: I've tried to organize such efforts, but that sort of
speaker's bureau has been largely unsuccessful. The drawback is that
people currently using drugs are hiding, those who've been caught using
are in prison, and those in recovery are afraid of coming forward because
of stigma and discrimination they want to remain anonymous.
So, it's unfortunate, but the dominant messages reaching the public
are negative. The successes remain out of sight and out of mind.
[Readers: We'd like to hear of any experiences in organizing speakers
to reach out to the community with their methadone treatment success
stories. Write or fax us. -ed]
Survey: Managed Care and MMT
In the last edition of A.T. Forum, readers were asked to respond to
the question: "What is your opinion of MMT patients and/or programs
coming under managed care plans? Good idea? Bad idea? Or, uncertain?
Among those responding, 23 percent thought it was a good idea and 35
percent thought it was a bad idea. And, for the first time the majority
(42 percent) of A.T. Forum readers who tend to have rather solid
opinions one way or another on issues - were uncertain about the pros
or cons. This may be indicative of just how difficult it is to understand
the various nuances of managed care, and many responses showed that
readers are still unclear on the concept. Here is a sampling of comments:
In favor of managed care...
Operations specialist, Hawaii "Since managed care is here to stay,
we need to meet with the plans to provide [them] education and advocacy
on behalf of the patients. In Hawaii we have been working with managed
care for two years. The plans still do not fully understand methadone
treatment, but [our executive director] is working on it."
Clinic coordinator, Maryland "Depending on the quality of the managed
care organization, treatment may improve. It may even encourage a move
to medical maintenance."
Executive director, New Jersey "Because of the abuses of Medicaid
funding, managed care has some merit. If MMT patients' primary care
doctors are their treatment doctors, it would probably work much better."
Opposed to managed care...
Counselor, California - "I am concerned that there is not enough
education about methadone for it to be under managed care."
Patient, Connecticut "It appears to me, managed care people are
not sensitive to the needs of MMT patients or knowledgeable about addiction."
Program coordinator, Maryland "Managed care will limit treatment
for patients resulting in ineffectiveness... they will not be afforded
long-term treatment if needed."
Uncertain...
Few readers included written comments with their "uncertain"
responses. One executive assistant, from Pennsylvania echoed the A.T.
Forum article's expressed concerns about MMT programs remaining
separate, or carved-out," of statewide managed care initiatives:
"Carve-outs are sometimes very vulnerable because they are easily
identified and become targets."
During an interview with David Mactas, director of CSAT, for another
article in this edition of A.T. Forum he expressed concerns about the
potential impact of managed care regarding addiction treatment: "I'm
not certain that the chronic nature of [substance abuse] disorders is
adequately addressed by managed care," he said. "It [managed
care] would be attractive if it could cut expenses while retaining patients
in treatment. Although, long-term patient retention might not be viewed
as a positive factor [by managed care organizations]."
Finally, an anonymous response expressed displeasure with the article's
presentation of the issues: "As a managed care director I do not
look forward to dealing with [methadone treatment] providers and their
attitudes as fostered by your magazine and its attitudes: i.e., the
'specter' of managed care; 'denying' freedom of choice; 'forcing' patients...."
[We should note that it was not our opinions (or "attitudes")
expressed in the article, but those of the persons we interviewed. If
Mr./Ms. "Anonymous Managed Care Director" would care to come
forward, we will be pleased to present his/her viewpoints.-ed.]
Addiction Treatment on the Internet
Here are some Web sites of interest dealing with methadone and addiction
treatment issues. All were active as of last November and are updated
regularly:
CDRWG offers important news, reports, and lots of links to other
worthwhile sites from the Chemical Dependency Research Working Group
of OASAS...
http://www.users.interport.net/~nama/cdrwghom.html
Methadone Today is the official online newsletter of DONT (Detroit
Organizational Needs in Treatment) which is a chapter of NAMA. It features
lots of interesting and well-written articles...
http://www.tir.com/~yourtype/
Methadone Information Exchange is a project of methadone patient
Eric Peterson and features letters and discussions for and by patients...
http://members.aol.com/methinfex/index
A.B.A.T.E. stands for Advocates for the Betterment of Addiction
Treatment and Education, which is organized by and for persons in recovery,
and covers all addictions...
http://www.nordex.int.com/abate/
Feedback: Horrifying Attitudes
"I was really pleased to read the Fall 1996 issue of Forum
regarding MMT and the impact of staff attitudes on success in treatment.
For years I worked in the methadone maintenance system and was horrified
by the attitudes of the nurses, counselors, physicians and administrators.
We claim to hold a disease model belief system in America, but we practice
a moral/criminal model which treats 'patients' like dumb children who
need to be controlled and parented at best, and psychopathic criminals
who need to be controlled and punished at worst."
"If part of the healing process is to normalize drug users and
allow them to take a full place in society... people should be able
to receive this medical regimen [methadone] at the family doctor's or
other primary care treatment situation. We don't make diabetics go to
a program. Why do we treat the 'disease' of chemical dependency differently
than the disease of diabetes? Because treatment professionals do not
really buy into the disease model, they just give it lip service."
"For so many years, methadone treatment staff have been on the
defensive, since our moralistic society does not approve of this treatment.
Thus, they are paranoid, afraid of criticism, isolationist, and hostile
to working with other workers from other systems, like AIDS organizations
or the patient's family doctor."
"MMT is, in my opinion, the most effective form of drug treatment
that we have for opioid dependence. However, the way we implement it,
with more DEA input and government restrictions than treatment input
and no consumer input, reduces the success of this treatment and reduces
the contentment of the consumers."
"We must revamp the system, lay out the ethics of methadone treatment
(e.g., reducing medication dosage as a punishment is medical malpractice),
and weed out the workers with bad attitudes even though this will require
replacing a majority of the treatment staff. At least in the abstinence
modalities the workers actually believe in what they are doing, even
though their success rates are quite poor (only 5-10%)."
"Here's to methadone maintenance, and may it improve along with
A.T. Forum's help in putting out accurate information and informed
recommendations."
Edith Springer, A.C.S.W.
Clinical Director,
N.Y. Peer AIDS Education Coalition, Inc.
Patient Perspectives
Some time ago, A.T. Forum featured an article on "The 'Graying'
of Methadone," calling attention to the possible special needs
of older patients in MMT programs. It generated a large volume of reader
response, and led to the insightful interview which follows...
Simon Says... "Give Me A Break Already!"
"Simon" not his real name for confidentiality purposes is
67 and lives on the east coast. He's been in methadone maintenance treatment
for the past 22 years. Before that, he was a heroin addict for 25 years,
starting at age 20. Since he went on methadone in 1974, Simon claims
he's had a perfectly clean record, yet he's concerned as he gets older
that, "There should be something better for patients like me, other
than my twice weekly clinic visits for pick-ups."
For one thing, to pick-up his 100 mg/day doses of take-home methadone
twice each week, Simon has to take two buses each way; consuming much
time and precious money. A real scare came one winter when there were
heavy snow falls crippling the entire east coast. "Every winter
it gets more difficult for me just to get to the clinic," Simon
says, "and that winter really scared the hell out of me."
Can't his family help him get to the clinic? "Nobody in my family
knows that I'm a methadone patient, except for my wife," he says.
"I have grown children and grandchildren, and if they by chance
see me walking into a methadone clinic it certainly would be upsetting
to me and to them." By the time his children were old enough to
realize Simon's problem, he was already "cleaning-up his act"
via methadone, and his grandchildren certainly have no clue that grandpa
was a "junkie" and is now "cleaned-up" on methadone.
The specter of stigma plays an important and often negative role in
addiction recovery.
Why did Simon eventually decide on methadone maintenance treatment?
He admits that, during a 25 year period while on heroin, he spent at
least nine years in jail just for heroin possession not for any other
criminal activities (e.g., assault, robbery, etc.). During each jail
term he went through painful drug withdrawals, and each time he went
back to heroin after release; sometimes the very same day. "I finally
got tired of waiting on street corners for a heroin connection, especially
on cold winter nights when I'd start mumbling to myself: 'Where is he?
When will he get here? I almost hope the jerk doesn't come... but, I
desperately need a fix!'"
Simon first heard about methadone in the 1960s - which were the very
early days of methadone treatment research for opiate addiction - but,
he always hoped he could get off heroin on his own. It finally got to
the point where he accepted that there must be a better way than self-control,
or detox which had never worked in the past.
Today, Simon questions the need for his going into a comprehensive MMT
clinic twice-weekly: "Most of the counselors seem like capable
folks," he says. "But they're younger than my own children!
So, even if I did have a problem, I couldn't comfortably bring it to
them. Over the years, I've been through so many tests, and counselors,
and psychiatric evaluations... it gets to a point where I must say:
'Leave me alone, already. I'm on methadone. I'm doing just fine, thank
you. Please find some ways to give me a break and make my life easier
in keeping-on with this marvelous treatment!"
What about detoxing from methadone and living a totally "drug-free"
life? Simon says, "The clinic people always bring up the subject.
But, I detoxed so many times from heroin and always went back that if
I ever got off methadone I'd probably just go back to heroin. At my
age, having done so well on methadone for so long, how can the clinic
staff respond when I say, 'Forget that detox talk; I don't want to go
back to heroin!'" So far, the staff has heeded his pleas.
Would a medical methadone maintenance program be helpful, so Simon could
just visit a primary care physician periodically for methadone prescribing
and wouldn't have to go to a public clinic at all? Simon says a major
hurdle is that he's retired now and not working, and those programs
[still new and experimental in the U.S.] require that patients are actively
employed. Somewhat frustrated, he says, "That's [the employment
requirement] just fine, but when I was productively employed all those
years and on methadone, nobody bothered to do anything to help me cope
with the required and frequent clinic visits, even during working hours.
I've been on methadone for so long and a good patient for 22 years,
that I feel I've paid my dues... I deserve a better way, in my old age,
for getting the medication that controls my addiction. I shouldn't still
have to go to a clinic twice a week and give urine samples to pick up
my bottles of methadone."
Avoiding the stigma associated with methadone treatment is an ongoing
concern for Simon. Recently, he was elected as a respected officer in
his local neighborhood organization. He says, "Can you imagine
how they'd feel about me if they found out I was a methadone patient!?
I'd still be the same person, but the way they'd look at me, and think
about me then... forget about it! I might as well move someplace else."
Finally, Simon emphasizes that there's a strong need for an increased
understanding about what MMT is all about to overcome the stigma surrounding
it. And, for older patients like himself there should be more lenient
approaches to treatment regimens and easier accessibility to the medication.
He says, "It seems, nobody knows about the long-term MMT patients
who are out there, not bothering anybody and living their private, productive
lives. Those patients or clinic operators who are featured in methadone-bashing
newspaper or TV stories are the goof-offs! But, the many thousands of
methadone patients that go to work each day, or live quiet lives in
retirement like me, and raise families, pay taxes, and are good citizens...
we're invisible! The public only hears the bad sides of the stories...
and that's very wrong!"