AN OVERDOSE OF OVERDOSE DEATHS:

Under that catchy headline the Sun Sentinel (Fort Lauderdale, Florida) calls for heightened "crackdowns on doctor-shopping and unscrupulous 'pill mills'” (June 17). Americans have for decades paid a staggering price for the counter-productive "war on drugs" precisely because of hasty, unfounded, knee-jerk conclusions that doing more of the same will lead to different outcomes. The newspaper offers nothing to suggest the problem of rising overdose rates lies with patients seeking care from a succession of doctors, or with healthcare providers who act "unscrupulously." It seems reasonable to hold proposed solutions in abeyance pending a more thoughtful, evidence-based analysis. It might be, for example, that guaranteeing affordable treatment options for all who want and need them would be vastly more effective than ever more “crackdowns.”

THE CUSTOMER IS (OR SHOULD BE) ALWAYS RIGHT

– BUT HOW ABOUT PATIENTS? A just-published report by Gruber and colleagues (Drug Alc Dep 94:199-206,2008) presents findings of a clinical trial carried out more than a decade earlier. One interesting facet is the diametrically opposite views of authors and “subjects” regarding detoxification. The former dismiss detoxification without qualification as “not an effective treatment.” The subjects, on the other hand, had “voted with their feet;” all were recruited from a voluntary, ambulatory, 21-day detoxification program. “Complete informed consent procedures” were applied, but one must wonder if the information provided (by the researchers and by their clinical colleagues) included the judgment that detoxification was deemed ineffective. At any rate, the seeming dichotomy in perspective might be explained as reflecting the common view of many professionals that achieving and maintaining long-term abstinence is a sine qua non of therapeutic success, while in this study “… only a third [of the detoxification patients] stated they wanted to quit heroin completely; most were hoping to use less or use more safely.” Measured by this more modest, but nonetheless meaningful, objective, detoxification would seem to be an eminently reasonable and promising option.

THE RATIONAL, AND THE IRRATIONAL:

First the rational, from Ontario, Canada (Peterborough Examiner, 21 June), the headline says it all:
"Methadone clinics like any clinic: city planner; Report rejects restrictions on where they can go." Bravo!

But on the same date from the other side of the world, a Melbourne, Australia, newspaper The Age headline notes, "Methadone too costly for addicts; call for government to help pay fees". In the meantime, as government mulls over what it should do, many patients are turning to the only sources available to pay for their potentially life-and-death treatment: "The cost of methadone programs is driving some recovering heroin addicts to turn to sex work and crime, skip meals, or abandon treatment and relapse into heroin use, a report has found." So much for the claim that opiate dependent people are not motivated to get help! But what a travesty, and how tragic for patients as well as the general community!

UNITED STATES: DISCRIMINATION CLAIM SETTLED:

A company agrees to settle a discrimination claim filed by The Equal Employment Opportunity Commission (EEOC) on behalf of a qualified employment applicant who was denied employment because he was receiving methadone treatment for pain. For Full Story CLICK HERE

CANDIDATES ON METHADONE:

Senator McCain had the following to say about methadone treatment back in 1999:

"Methadone maintenance programs simply transfer addiction from one narcotic to another. ...[With methadone maintenance] the federal government trades places with the street dealer, swapping heroin for methadone and feeding the addiction with taxpayer dollars. This is disgusting and it is immoral." (Entire speech on floor of Senate, May, 1999, accessible at http://www.methadonetoday.org/v4_n05.htm )

We've seen nothing more recent from Senator McCain on methadone since - nor any mention of methadone ever in any speech by Senator Obama. If anyone has more information on the stated positions of the two candidates, we'd appreciate being informed.

"PATIENTS" OR "CLIENTS" - WHAT'S IN A NAME? - PLENTY!!!

Deng Xiao Ping once said: It doesn't matter if a cat is black or yellow, as long as it catches rats." Well, in terminology as applied to those treated with methadone, semantics do matter.

Dole and Nyswander loved non-physician staff and considered them essential to optimal care of patients. They employed lots of methadone patients as staff members. When Rockefeller University and Beth Israel and other academic institutions claimed these "non-professionals" didn't fit into any accepted human resource category, Vince decided on the title, "research assistant" - and that's what they were called for many years, then some folks decided these non-physician and non-nurse "support staff" had to be made into "real" professionals = which in turn mandated that they be trained, certified, licensed, degreed, etc etc etc - and this new "profession" then demanded the rubric "client" be used to define those who received their care. I believe the reason is that only in this way could they exert direct power (for good or for bad is not the issue - power is power) over those they "served." Anyone can serve "clients" - but "patients" are generally understood to be under the care of physicians, for whom and with whom, but under whose ultimate authority, non-physician staff work.

In truth, sadly, most programs seem to relegate physicians to doing little more than signing medication orders - and even that I believe is usually done pursuant to the specific instructions of the non-physician staff, who generally decide how much medication, whether there should be take-homes, who should be "terminated," etc. The result: treatment of the disease of opiate dependence is absolutely unique - and lots of practices that would be unthinkable in all other areas of medical care are routine.

One of these days a physician will be faced with loss of medical license because s/he imposed a "cap" on doses, or lowered dosage as "punishment" for infraction of some rule or other, or ordered "taper" and termination because of toxicology results confirming the patient had the problem being treated, or .... And when that doctor states that "the counselor made me to do it," I suspect the current situaiton may change.

Contrary views, as always, welcomed. bob newman