From the Publisher

This is YOUR Forum; We Look Forward to Hearing from You

We hope you enjoyed reading the newly redesigned Winter 2008 AT Forum newsletter. Your participation in this exchange of ideas for the addiction treatment field is essential. Send us your thoughts, comments, and criticisms. We would also like to hear what you and your OTP are doing, so send us news about new programs or plans. This will truly make this newsletter a “forum” representing the views of addiction treatment professionals and patients. You can respond to us by e-mail, phone/fax, or mail (see below).

As a reminder, if you would like to obtain a free subscription to the newsletter for yourself or for a friend or colleague, please contact us (see below).

In this Issue

Should OTPs provide take-home doses for days when the facility is closed: Sundays and state or federal holidays? This has long been the accepted practice. But in January 2008, the Center for Substance Abuse Treatment (CSAT) issued a letter “restating” this practice. In this issue we recap the response from AATOD (The American Association for the Treatment of Opioid Dependence) to CSAT’s letter. We also include brief excerpts from Dr. Clark’s May 1 reply to AATOD, and his May 14 “Dear Colleague” letter, which includes examples of recommended labels for take-home medication bottles. (For links to both letters, see AATOD Responds to CSAT Fuidance on Methadone Take-Homes).

Who are today’s OTP patients, and how do they differ from those in the past? In this issue we look at OTP patient trends over the past 40-plus years. We cover census growth and demographic and socioeconomic changes. Patient characteristics have undergone a marked change because of rapidly increasing admissions for prescription opioid dependence. This article, “Changing Profiles of Patients Entering OTPs. . .” is a continuation of our series on the Past, Current, Future of Medication-Assisted Treatment (MAT) in Opioid Treatment Programs (OTPs).

We hope you find these articles and others in AT Forum to be informative and helpful. We’re looking forward to hearing from you.

Sue Emerson Publisher
ATForum@ATForum.com

AATOD Responds to CSAT Guidance On Take-Homes

Methadone-related deaths in the U.S. continue to rise—a fact that some treatment providers believe may underlie the recent action of the Center for Substance Abuse Treatment (CSAT) in issuing a guidance letter on take-homes to opioid treatment programs (OTPs) (see below). But, contrary to some news reports and lay opinions, most methadone-related deaths are not linked with OTPs, but are associated with methadone that has become available through hospitals, pharmacies, or primary-care or pain-management physicians.

CSAT Issues Guidance Letter on Take-Homes

A major concern behind issuance of the letter, which has been called a restatement of federal regulations, was the safety of patients who are in the induction phase of treatment, and haven’t been stabilized on their methadone doses. Another was the concern by some about the possibility of methadone diversion. Existing federal regulations stipulate that any patient in an OTP may receive one take-home methadone dose for a day when the facility is closed: Sundays and state and federal holidays. Many recipients, including AATOD, JCAHO, CARF, and the Legal Action Center, interpreted the CSAT letter to mean that, in order to comply, OTPs would be required to be open seven days a week, or make alternative arrangements for patients who do not meet the eight strict criteria for take-home methadone doses (see sidebar below for criteria).

The restatement was spelled out in a “Dear Colleague” letter H. Westley Clark, MD, JD, MPH, Director of CSAT, sent to OTPs on January 24, 2008. CSAT is a division of the Substance Abuse and Mental Health Services Administration (SAMHSA). Dr. Clark’s guidance letter suggested that on closure days, “the OTP could have an arrangement with a medical facility (hospital) or another OTP in the community to permit the patient to be medicated under appropriate medical supervision. Or the OTP may decide to open for a limited period of time to dispense to patients not eligible for the take-home supply.”

AATOD TO CSAT: Please Clarify

The CSAT restatement letter caused concern in the treatment and state regulatory system. In a March 10 reply to CSAT, Mark Parrino, MPA, noted, “(A) number of treatment programs interpreted your letter to mean that they should maintain daily operations and begin such daily operations soon after receiving your letter.” Mr. Parrino is president of the American Association for the Treatment of Opioid Dependence (AATOD). Mr. Parrino’s communication included comments from several organizations that take issue with CSAT’s restatement of the regulations.

Legal Action Center Perspective

According to Catherine H. O’Neill, senior vice president of the Legal Action Center, New York, “SAMHSA clearly appears to consider its ‘restatement’ of Federal policy to be a non-binding advisory communication of its ‘current thinking’ on the take-home provisions of the OTP regulations rather than an enforceable standard of practice.” She further noted, “SAMHSA does not have the authority to supersede 42 C.F.R. Part 8 [the pertinent section of the Code of Federal Regulations] simply by means of sending this Dear Colleague letter.”

Accreditation Organizations’ Perspective

Joint Commission for the Accreditation of Healthcare Organizations (JCAHO)

In a February 29 letter to AATOD, Mary Cesare-Murphy, PhD, Executive Director of Behavioral Health Care Accreditation, The Joint Commission, commented: “Currently the Joint Commission does not hold opioid treatment programs responsible for using the 8 point criteria listed in 42 CFR Section 8.12 (i)(2)* for take home medication given on Sunday and Federal holidays.” But she added that the Joint Commission is ‘”currently in the process of reviewing and revising the Opioid Treatment Program Accreditation Standards, in keeping with the recent revisions to the CSAT ‘Guidelines for the Accreditation of Opioid Treatment Programs.’’’

Commission on Accreditation of Rehabilitation Facilities (CARF) International

Darren Lehrfeld, Chief Accreditation Officer and General Counsel for CARF International, one of the federally approved accreditation entities, commented, in a letter to CSAT, ”(I)t does not appear from a strict construction of the regulations that the responsibility determination required by 8.12(h)(4)(i)(2)* is necessary for situations when the clinic is closed for business and a single dose is to be dispensed. If the determination were also required in those situations, there would be no reason for the inclusion of 8.12(h)(4)(i)(1).”‡

Additional Concerns

In his letter to CSAT, Mr. Parrino of AATOD said, “A number of treatment providers and patient advocates have expressed considerable concern” about the financial consequences the policy restatement and stricter regulations would have on states, OTPs, and patients. Being open on Sundays and holidays would greatly increase operating budgets. Employee union contracts would pose problems in some areas.

But making alternative arrangements—sending patients to another site for a Sunday or holiday dose—would entail logistic, confidentiality, and perhaps legal issues, and would raise out-of-pocket travel expenses for hundreds of thousands of patients. Public transportation on Sundays and holidays is limited or unavailable in some areas. Mr. Parrino noted another problem: efforts to arrange medication at hospital emergency departments have met with resistance because of record-keeping, insurance, risk-management, and billing issues.

Mr. Parrino has a practical approach. “Our plan has been to encourage OTPs to be more considerate in their clinical judgment about which patients take home unsupervised doses of medication.” Mr. Parrino pointed out that OTPs have been operating under the current plan for more than 40 years. “Millions of take-home doses have been dispensed over the course of this time without any credible report being released linking such dispensing practices to methadone-associated mortality.”

CSAT Responds to AATOD’s Concerns

On May 1, Dr. Clark replied to AATOD: “It was not SAMHSA’s intention to suggest that OTPs must remain open seven days a week,” but rather to “emphasize the importance of assessing patients for stability and responsibility prior to receiving unsupervised take-home doses, even for Sunday and Federal and state holiday closures.” Dr. Clark’s May 1 letter may be accessed by clicking here http://www.atforum.com/pdf/csat/20080501.pdf

CSAT Issues Guidance on Take-Home Medication Labeling

On May 14, Dr. Clark sent another “Dear Colleague” letter, this one emphasizing that according to 42 CFR, take-home medication bottles should be properly labeled with the OTP’s name, address, and telephone number. He noted that SAMHSA recommends also including on the label the name of the patient, physician, and medication, and the dispensing date. He added, “We believe that the inclusion of the above information on take-home bottle labels will help reduce diversion of methadone and buprenorphine and improve patient safety.” Dr. Clark’s May 14 letter, which includes samples of recommended labels, may be accessed by clicking here http://www.atforum.com/pdf/csat/20080514.pdf

*Decisions on dispensing more than a single take-home dose for a day when the clinic is closed are to be made by the medical director, using the eight take-home criteria.

‡Any patient in comprehensive maintenance treatment may receive a single take-home dose for a day that the clinic is closed for business, including Sundays and state and federal holidays.

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OTPs: Past, Current, Future Part II

Publisher’s note: This is the second in a series of articles exploring changes that have occurred in Opioid Treatment Programs (OTPs) since the inception of Medication-Assisted Treatment (MAT) in the 1960s. The Winter 2008 edition of AT Forum reviewed changing attitudes toward opioid dependence and its treatment that were influenced by key reports and regulations from the 1990s. These key events continue to transform MAT. In this issue, we will focus on how the characteristics of OTP patients have changed over the last 10 to 15 years.

Changing Patient Profiles in OTPs

OTP Admissions Continue to Grow

The number of patients entering MAT in OTPs has grown steadily through the years.

Starting with only 400 patients in 1968, the number of people entering OTPs has more than doubled between 1993 and 2006, from 117,000 to 260,000 (see Figure 1).

 

Patient Population is Changing

Characteristics of patients entering OTPs have changed significantly over the past decade.

• Patient admissions for prescription opioid dependence are rapidly increasing.
• Younger and older people are entering treatment.
• Today’s patients are more likely to be entering treatment with multiple substance-abuse disorders.
• More new patients have co-occurring physical or mental health disorders or both.
• Still, patients are becoming more educated about MAT, they’re taking a greater part in helping other patients, and they’re interacting more closely with their OTPs. The past decade has seen a rise in patient advocacy.
  

Prescription Drug Abuse on the Rise

Prescription drug abuse is a significant, emerging problem in the U.S. that has led to an influx of patients entering treatment for prescription opioid dependence. According to the 2006 National Survey on Drug Use and Health, 7 million people took prescription drugs for non-medical purposes during the past year.

Admissions to all substance-abuse facilities for patients whose primary substance of abuse is prescription opioids increased 360 percent in the past decade. In 2006, prescription opioid abusers accounted for 22 percent of all opioid admissions, compared with only 6 percent a decade ago (see Figure 2).

Patients are Younger – And Older – Than Before

Heroin- and prescription opioid-dependent patients are entering treatment at an earlier age. During the past 10 years, the percentage of people age 20 to 24 admitted for heroin abuse increased by two-thirds, while the percentage more than doubled for prescription opioid admissions.

Patients entering treatment are older than before. Some methadone-maintained patients have aged while in MAT, and others are entering treatment for the first time in their 50s, 60s, and 70s.

The percentage of heroin admissions among people age 50 and older has more than doubled in the past 10 years. While prescription-opioid admissions among that same age group have remained stable over the past decade, the National Institute of Drug Abuse indicated that their number could rise 190 percent over the next two decades.

Patients Are Demographically More Diverse

Patients entering treatment for prescription opioid-dependence are different demographically than patients entering treatment for heroin abuse.

Patients admitted for treatment of prescription opioid-dependence in 2006 were more likely to be white, female, to have some college education, and to be employed full-time, compared to heroin admissions (see sidebar).

Secondary Substance Abuse is on the Rise

In the early years of MAT, the majority of patients entering OTPs abused only heroin. Today, approximately two-thirds of heroin- and opioid prescription drug-abusers entering substance abuse treatment reported at least one secondary substance of abuse.

Prescription opioid-dependent admissions are more likely to report secondary use of marijuana, while heroin admissions are more likely to report cocaine as a secondary substance of abuse.

About one-fourth of both patient groups are also dependent on alcohol.

Treatment Needs are More Complex

The treatment of opioid dependence is often compounded by other physical and mental disorders in OTP patients, including hepatitis B and C, HIV, and mental illness.

Infection with hepatitis C virus (HCV) – a common complication of injection drug use – is now the most prominent and worrisome co-occurring physical disease among OTP patients. The prevalence of chronic HCV infection is estimated to be 67 percent to 96 percent in patients enrolled in OTPs. Yet most OTP patients are not receiving treatment for HCV, and no vaccine is available (See article below).

Since the HIV epidemic began, injection drug use has directly and indirectly accounted for more than one-third (36 percent) of all AIDS cases in the United States. In 2006, injection drug users accounted for 13 percent of HIV/AIDS diagnoses, compared with 22 percent just three years earlier.

Improved screening and prevention methods among OTP clinicians and patients, as well as aggressive treatment options, have helped diminish the prevalence of HIV/AIDS and other infectious diseases, such as tuberculosis. They also have greatly increased the quality of life among patients who are infected.

Opioid addiction and co-occurring mental disorders are also common in patients entering OTPs. Reports have varied, but overall, nearly three-quarters of OTP patients may have experienced a mental illness of some sort during their lives. More than half have a mood disorder, such as depression or anxiety, when entering treatment.

Patients are More Involved

Today’s OTP patients – especially older individuals who have been in therapy continuously or repeatedly over many years – are well-informed about their treatment. Longer-term methadone patients often provide OTPs with valuable insight about meeting patients’ needs. They also suggest reasonable goals and expectations of treatment.

Some programs have added patients to their advisory boards and organized patient advisory committees. In some cases, those boards and other patient liaisons have helped OTPs respond to patient and community concerns before the concern became problematic. Many clinics also seek input from their patients via patient satisfaction surveys that ask: “What do you think of the treatment you’re receiving? What is working for you? What isn’t?”

Today’s patients are also effective treatment allies, engaging in activities that help extend the treatment network. The National Alliance of Methadone Advocates has led the movement to protect patients’ rights and to ensure that their perspectives are heard by providers and policymakers. Methadone-based recovery peer-support groups, such as Methadone Anonymous, are rapidly expanding, giving patients opportunities to interact outside an OTP with others who have been in or have completed treatment.

Battle against Stigma Continues

The disclosure through scientific research that addiction is a chronic disease, bolstered by examples of successful recovery, has tempered the stigmatizing of OTP patients and their treatment. But while progress has been made, the stigma still continues to affect patients in many ways. It can:

• Discourage people from entering MAT or cause them to leave treatment early.
• Create health-care barriers. For instance, some physicians may be inclined to limit pain medications for people who are opioid-dependent. In addition, the refusal of some organ transplant programs to provide liver transplants to patients maintained on methadone may be a result of stigma. The lack of convincing data on outcomes for methadone patients who receive transplants may also play a role.
• Affect the attitudes of employers, families, and friends of people who are opioid-dependent.
• Hinder acceptance by the mainstream recovery culture. As an example, OTP patients can attend Narcotics Anonymous meetings, but only those who are abstinent from all drugs, including methadone, are welcome to speak.

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Sources:

AT Forum Spring 2007. http://atforum.com/newsletters/2007spring.php

Center for Disease Controls (CDC) Viral Hepatitis and Injection Drug Users September 2002. http://www.cdc.gov/idu/hepatitis/viral_hep_drug_use.pdf

Center for Disease Controls (CDC) Drug-Associated HIV Transmission Continues in the United States Fact Sheet 2002. http://www.cdc.gov/hiv/resources/factsheets/PDF/idu.pdf

Center for Substance Abuse Treatment. Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs. Treatment Improvement Protocol (TIP) Series 43. DHHS Publication No. (SMA) 05-4048. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2005. http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.chapter.82676

National Institute on Drug Abuse Prescription Drug Abuse (NIDA) – March 2008. http://www.nida.nih.gov/pdf/tib/prescription.pdf

National Institute on Drug Abuse (NIDA) Comorbid Drug Abuse and Mental Illness October 2007. http://www.nida.nih.gov/pdf/tib/comorbid.pdf

National Institute nf Drug Abuse (NIDA) Science & Practice Perspectives, Volume 3, Number 1 - December 2005 Methadone Treatment at Forty Marion IJ. http://www.nida.nih.gov/PDF/Perspectives/vol3no1/Methadone.pdf

National Institute on Drug Abuse National Institutes Scientific Research on Prescription Drug Abuse, Before the Subcommittee on Crime and Drugs, Committee on the Judiciary and the Caucus on International Narcotics Control United States Senate. Nora D. Volkow, M.D. Director of Health Department of Health and Human Services March 12, 2008. http://www.drugabuse.gov/Testimony/3-12-08Testimony.html

Substance Abuse and Mental Health Services Administration, Office of Applied Studies. National Survey of Substance Abuse Treatment Services (N-SSATS): 2004-2006. http://oas.samhsa.gov/dasis.htm#nssats2

Substance Abuse and Mental Health Services Administration, Office of Applied Studies. Treatment Episode Data Set (TEDS). 1997 - 2006. http://oas.samhsa.gov/dasis.htm#teds2

 

Infection with Hepatitis C Virus in Methadone Maintenance Patients

Bringing HCV Therapy to MMT Patients

Hepatitis C virus (HCV) is a common complication of injection drug use. A literature review (Novick and Kreek 2008) found the prevalence of chronic HCV infection to be 53% to 96% among injection drug users, and 67% to 96% in patients enrolled in methadone maintenance treatment (MMT). Most MMT patients are not receiving treatment for HCV, and no vaccine is available. Among those infected with HCV, there is also the problem of possible co-infection with human immunodeficiency virus (HIV), the organism that causes AIDS.

Although HCV infection often has no symptoms, over time it can cause liver damage, cirrhosis, and liver cancer. Treatment for HCV-infected patients includes antiviral drugs, and in some cases, liver transplantation. For most patients who are infected with HIV in addition to HCV, antiretroviral therapy for HIV infection is usually the first priority.

The authors of this study concluded from their extensive review of 153 references that antiviral therapy for HCV is appropriate for MMT patients. Therapy results in acceptable rates of adherence and a sustained virological response (being virus-free 24 weeks after the end of treatment). Because methadone does not damage the liver, the dose need not be changed in patients who have stable chronic liver disease, including advanced cirrhosis. The authors further state that there is no scientific or clinical reason to withhold antiviral treatment, and that the data support increased efforts to treat MMT patients.

The 2002 National Institutes of Health Consensus Document Conference statement on the management of hepatitis C recommended increased consideration for antiviral therapy for patients in MMT, injection drug users who are likely to comply with therapy, and patients co-infected with HCV and HIV. Novick and Kreek have found that the reasons most MMT patients infected with HCV are not receiving treatment include the patients’ lack of knowledge and understanding of HCV disease; financial, legal, and logistic concerns; and, in some cases, underlying psychiatric disorders that prevent patients from seeking or accepting treatment.

Based on their review, the authors suggest some steps that may help provide effective HCV therapy for MMT patients. These steps include using multidisciplinary teams that offer pretreatment medical and psychiatric evaluations, and that follow up with comprehensive primary care for medical and psychiatric problems. In particular, psychiatric medications have been found to improve adherence in many patients. Additional steps to deliver HCV therapy to MMT patients include providing patient education and HCV counseling, testing, and treatment, and establishing treatment sites that are acceptable to patients. These are not always the site of methadone treatment. The authors conclude from their review that these steps can help deliver to methadone maintenance patients the high-quality medical care that is already available to other HCV patients for all aspects of HCV infection.

Source:
Novick DM, Kreek MJ. Critical issues in the treatment of hepatitis C virus infection in methadone maintenance patients. Addiction. In press. Published online April 18, 2008. Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/18422827?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_Results
Panel.Pubmed_RVDocSum. Accessed May 1, 2008.

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News from the States

Indiana Methadone Clinics to Get More Oversight

New and tighter methadone clinic regulations in Indiana call for a reduction in take-home doses. Random testing for marijuana will be required. The new regs stop short of requiring designated drivers and prohibiting children from entering facilities.

Gov. Mitch Daniels recently signed Senate Bill 157 (effective July 1, 2008), which includes the following requirements for clinics:

• All methadone-treatment programs must periodically and randomly test – including prior to admission – for drugs, including marijuana, methadone, cocaine, opiates, amphetamines, barbiturates, and benzodiazepines.
• The maximum take-home period has been reduced from 30 days to14. The original bill proposed reducing the take-home period to three days.
• The mental health division will establish and maintain a central registry of all patients in the state being served by methadone-treatment programs.

Additional proposals that were considered but did not make it into law include:

• A provision that would have required methadone patients to have “designated drivers” take them home from the clinic after dosing.
  
• Automatic detoxification for anyone who provides a “dirty” urine sample.
  
• A provision that would have excluded children from clinics, even when parents or guardians were being treated.

The bill was introduced to help stop the flow of out-of-state residents seeking methadone treatment in southern Indiana. Some surrounding states, including Kentucky and Ohio, have limited treatment capacity. Also their methadone treatment laws are considered stricter than Indiana’s.

Source
The Evening News and The Tribune of Southern Indiana - 4/3/08.

 

ACTION Campaign Meets Enlistment Goal Ahead of Schedule

Less than four months after its launch in October 2007, the ACTION Campaign has already met its initial goal to recruit 500 agencies nationwide.

The ACTION (Adopting Changes to Improve Outcomes Now) Campaign originally had planned to meet its goal within 18 months. Campaign Director Kim Johnson now estimates bringing the total recruitment to 1000 agencies or more over the next year.

The ACTION Campaign was created to help addiction treatment and recovery service providers come together to make it possible for more people to recover from addiction. The Campaign stems from the Network for the Improvement of Addiction Treatment (NIATx), based at the University of Wisconsin-Madison, which aims to improve access to and retention in addiction treatment, while making process improvement a part of managing and delivering treatment. NIATx is funded by the Substance Abuse and Mental Health Services Administration (SAMHSA), the National Institute on Drug Abuse (NIDA), and the Robert Woods Johnson Foundation.

The Campaign focuses on three key actions for improving recovery-oriented systems of care (ROSC), an important CSAT priority:

• Rapid access to treatment
• Increased engagement by those in treatment
• A seamless transition from one stage of care to another

Experience has shown that any one of these key actions can make a difference. Agencies report positive impacts on client access and engagement, improved staff retention and morale, and increased revenue and funding opportunities. One small improvement in every 1000 newly recruited agencies could make a difference in the lives of 110,000 people affected by substance abuse, according to previous research conducted by NIATx.

For additional information visit http://www.actioncampaign.org.

ACTION Campaign Case Study

The APT Foundation was founded in 1970 as a non-profit community-based provider of substance abuse treatment services in New Haven, CT. In January of 2006 APT Foundation clients waited an average of 24 days between initial assessment and actually receiving medication through the methadone treatment program. By employing a set of rapid cycle process improvement techniques learned from NIATx the organization has reduced its average time of admission to just two days with most clients receiving treatment within a day and a half. Some of the process improvements that led to reduced wait time include:

• Creation of change teams to identify areas for improvement and monitor results as changes are made.
• Utilization of staff-conducted consumer walk-throughs to identify areas needing improvement in the admission process.
• Enhanced utilization of agency-based line data.

These process improvements reduced admission time (Figure 1), and the number of clients in treatment rose from under 1400 to over 1800 (Figure 2). Prior to joining the ACTION Campaign, APT Foundation’s census had been flat for several years. APT Foundation is currently working on improving retention in treatment using the same process techniques and has achieved retention of over 95% at the 6 month mark in treatment.

Increased census has led to improved financial performance for the 40 year old non-profit Foundation. The increased revenue has been used to open APT’s newest site, Access Center. The Access Center serves as the first point of contact for all clients where they are evaluated, can attend group sessions and receive one-on-one counseling. In the first month of operation (June, 2007), the Access Center experienced an increase of 60% in both screening and evaluation services as compared to the former admitting units. Increased revenue was also used to hire additional staff and create an employee incentive program shared by all staff.

 

MAT Restores IDUs' Immune System

It's long been known that injection drug users (IDUs) have more infections, especially hepatitis C infection, than the general population. Now there is increasing evidence that heroin and morphine suppress the immune system. This suppression, along with the exposure associated with non-sterile injections, results in the high rates of infection in IDUs. Importantly, methadone does not suppress the immune system. So switching to Medication-Assisted Treatment (MAT) methadone or buprenorphine from heroin gives the patient's immune system a boost.

In the laboratory, leukocytes (white blood cells that fight infection in the body) continue their immune activities in test cultures. This allows investigators to find out how well heroin users can fight off infection, compared with MAT patients. Using this technique, Sacerdote et al (2008) compared the activity of leukocytes from former heroin users, currently maintained on MAT, with people who had never been injection drug users. They found that the leukocytes from MAT patients were not significantly different from the leukocytes from non-drug users. In contrast, leukocytes from heroin IDUs who were not on MAT were distinctly and significantly inhibited. In other words, in IDUs, the cells that should fight infection could not do so effectively.

This study helps to explain why infections are more common in injection drug users than in the general population. It also explains why MAT helps restore the immune system.

Source
Sacerdote P, Franchi S, Gerra G, Leccese V, Panerai AE, Somaini L. Buprenorphine and methadone maintenance treatment of heroin addicts preserves immune function. Brain Behav Immun. 2008 May;22(4):606-613. Epub 2008 Feb 21.

 

Window of Opportunity: Clinic Staff Member Hopes He Made a Difference

Publisher’s note: This is a recent installment of a monthly column Ben Guerrero writes for the Hersam Acorn Newspapers chain. AT Forum received the author’s permission to reprint an edited version of it for our readers.

By Ben Guerrero

In January 2004, I started working part time as a clinic attendant at a methadone program in Connecticut. I’ve been at the clinic from 6 to 10 a.m., five days a week, ever since.

Each day, patients enter the clinic and come directly to my window. They show me their I.D. We exchange a few words, and I send the patients to the medicating nurse. Of the ten employees at the clinic, the nurse and I are the only staff members the patients see every day.

As the months and years have passed, I’ve learned a little bit about each patient through our daily contact. Many clinic patients develop a hard, protective shell in order to survive on the street. Gradually I’ve chipped away at the shell. By greeting the patients and exchanging a few words, I have been able to offer them some dignity and respect. Gradually, through the glass at my window, I have made friends.

Many patients at the clinic have damaged their lives, their families, and their health. Some are trying to see hope ahead, the possibility of starting over. I believe I was able to help, by being a friendly face behind a window. I’d like to think I helped some of them hang on for another day, make another try.

As I type these words, I have 87 days to go until I take the national nursing exam. The clinic has been very supportive. But recently it became clear to me that something had to go if I were to survive my final months of schooling. I gave two weeks’ notice at the clinic.

I am finding, to my surprise, that leaving the clinic is far more difficult than I had imagined. I am saying goodbye to the patients one by one. There have been some tears on both sides of the window.

My parting is akin to a death in a large family. I leave with sadness, yet with optimism. Optimism for myself, and for the people I saw every morning, from 6 to 10, through my window.

As a family, we are all connected in some way by our struggles. Some are huge; others are miniscule. But sometimes, by helping others, we can put our own struggles aside. And sometimes, a little reaching out is all it takes—even if it is through a glass window.

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Events to Note

American Mental Health Counselors Association (AMHCA) Annual Conference
July 17-19, 2008
San Diego, California
Contact: 800-326-2642 or www.amhca.org

American Psychological Association (APA)116th Annual Convention
August 14-17, 2008
Boston, Massachusetts
Contact: 800-374-2721 or http://www.apa.org/

National Prevention Network (NPN) 21st Annual Research Conference
August 24-27, 2008
Indianapolis, Indiana
Contact: http://swpc.ou.edu/npn/

The Association for Addiction Professionals (NAADAC) Annual Conference
August 28-31, 2008
Overland Park, Kansas
Contact: 800-548-0497 or http://www.naadac.org

National Alcohol & Drug Addiction Recovery Month National Alcohol & Drug Addiction Recovery Month
September 2008
Contact: http://www.recoverymonth.gov/2008/default.aspx

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Updated August 8, 2008