Thursday, February 23, 2006

The "Real" Advantage of Buprenorphine over Methadone for Pregnant Patients and All Others... the Stifling, Dehumanizing, Stigmatizing, Bureaucratic, Community and Provider Hostility Directed Against Methadone in Many Places.

Lots of drug dependent people simply will not go to a "program" where they are observed while urinating, never ever trusted to be and remain in compliance, subject to fragmentation of care between those addressing the addiction and those focusing on all other problems the patient may have, etc. Any treatment that circumvents these commonplace horrors will attract some folks wanting and ending treatment that would stay on the streets rather than subject themselves to such a "system."



The VA operates the largest integrated health care system in America. The VA delivers health care largely through salaried staff who presumably follow orders when it comes to delivering medical care that is needed, and that is clearly effective. The VA has never been subject to limits on number of patients served by individual doctors or practice groups. The VA performed the nationwide study of "office-based" treatment of opiate addiction with buprenorphine - a study that became the major rationale for making this medication available in a non-"program" setting. And yet - in many states, it offers no buprenorphine at all (e.g., Hawaii, according to US Senate testimony given in January on behalf of the Hawaii Society of Addiction Medicine).Why does our Government tolerate this abandonment of those who have put their lives on the line for our nation? It's a disgrace.

Tuesday, February 21, 2006

NIMBY IN TORONTO: fears impervious to facts and experience

The Toronto Sun reports (Jan 31) on the fears of residents and businesses in the Corktown communtiy over the "proposed move a few blocks east" of a methadone program that for 15 years has operated "inoccuously." That the long-standing facility indeed is "inoccuous" is supported by the reporter's own observation: "Reconnaissance missions to [the clinic's] current address have turned up nothing that would give Corktown residents cause for seirous concern." The reporter goes on to state, "In fact, if one didn't know for certain that a methadone clinic existed ... there would be nothing to give it away." When it comes to NIMBY, facts and experience are irrelevancies.

Thursday, February 16, 2006

"Biggest drug bust ever in Columbia County"

(Capital Times, Feb. 2): Meaningless victories are often more accurate gauges of the course of war than stinging defeats. Here we have an apparently unprecedented law enforcement success in arresting dealers of heroin and prescription narcotics, but does anyone really believe for a moment it will result in fewer users and less consumption? When success has no relevance, it's time to reconsider the war we are waging.

Tuesday, February 14, 2006


The following question was posted recently on a drug-issues related list-serve. "How many clients is it safe to dose in a given time frame, and how much time should be allocated to each client."

A seemingly reasonable query, but ... With respect, when the option is to leave heroin dependent people who desperately want and need treatment out on the streets to shoot dope, "optimal" numbers to accommodate in methadone treatment becomes the wrong question - whether posed in absolute terms, or patients per hour, or services per patient per visit.

How bad or time-constrained does a service have to be to be a worse option than rejection and abandonment (if it were my kid, it would have to be pretty God-awful for me to agree with a decision that denied any/all help). As for specifics, for decades there have been clinics in Hong Kong that in the space of 45-60 minutes provide the individually prescribed dose of methadone to many hundreds of patients - and there the process includes first paying a $HK1 fee to the cashier, and the dispensing of meds is done not by nurses but by an "auxiliary medical staff"

Again, the burden is on the provider to justify abandonment on the basis of "we can't treat more patients. Considering the consequences for those NOT treated the threshold should be mighty high indeed.

(An additional observation: referring to "dosing" of patients seems demeaning and dehumanizing. Maybe one "doses" chickens or cattle, but patients are "medicated," - but hell, I guess it's much better to "dose" patients who need medication than to abandon them, which is the substantive issue here.)

Wednesday, February 01, 2006

“For the first time, help comes from the doctor’s office, not the methadone clinic.”

An article on Buprenorphine appeared January 24, 2006, in USA Today, with the above byline.

The availability of opiate-agonist maintenance treatment through prescription by office-based practitioners is a welcome and long-overdue development, even though the rationale for limiting the prescription-writing authority exclusively to Buprenorphine is not clear. What is distressing, however, is the apparent equanimity with which even the most knowledgeable experts in the field view the shortcomings of the government-designed and government-controlled system that has constrained methadone maintenance for the past four decades. That system is summarized by the news article in the following quote: "People who would never come to a methadone clinic, because it is both degrading and stigmatized, will come to a private physician’s office.”

This highly pejorative assessment of methadone maintenance facilities undoubtedly has some basis in fact. For sure, it reflects the perception of most Americans – and it would appear to be shared by Charles Schuster, to whom the quote is attributed. Schuster, however, is a former Director of the National Institute on Drug Abuse, and – along with virtually all of his colleagues in Government before, during or after his tenure – bears responsibility for the way in which methadone treatment is provided. What has he – and what have other leaders in the field of drug abuse treatment – done to lessen the degradation and stigmatization of “clinics”? Even now, as Schuster applauds the availability of Buprenorphine in private doctors’ offices, he seems to have zero concern over the roughly 200,000 patients who receive methadone under the only circumstances allowed by law.

The Government’s control over the facilities that offer methadone maintenance is absolute, and operating authority can be revoked for failure to adhere to any of the myriad rules, regulations and “standards” which apply. Why are degrading practices tolerated (in fact, many are required!)? What has Schuster done to lessen the stigma surrounding methadone treatment? What have other government, academic or clinic leaders in the field done? The most generous answer has to be, “Not enough!”