My final rant on this topic (I promise) is the issue of methadone clinics and Suboxone maintenance. Methadone clinics have been around longer and have always carried a degree of controversy with them. The idea is to replace one addiction with one that is more easily controlled. Methadone is also an opiate, but not as impairing as heroin and as it has a longer half life, only needs to be taken once daily. The hope is to get the addict of the crave-rush-crash-crave roller coaster they have been on. In general, the patients are supposed to go through a rigorous screening process to assess their motivation to truly get clean from opiate addiction and are regularly drug tested to ensure compliance with treatment. Most patients must come to the clinic daily to receive their once daily dose of methadone to ensure it is not abused. In some cases, it is given in a liquid form that must be taken in front of staff, but not always. Tablets are sometimes used, and it is not unusual for patients to "cheek" their tablets and turn around later and sell them, often in exchange for more potent drugs. The sale of methadone often occurs in close proximity to the clinics themselves and there was a recent legal battle with a community and a methadone clinic that wanted to open a clinic in close proximity to a school for that exact reason. Many of the clinics out there turn a blind eye to the extent as which this drug is being diverted and abused and how the services they provide are being manipulated.
In order to ensure compliance with treatment patients are subject to routine drug screening, but there are clinics that do not strictly enforce standards about abstinence. The idea with methadone use is that the patient must abstain from use of all other opiates to remain in treatment and unless prescribed by a physician, any other drug that could be abused. Truly good methadone clinics will not tolerate use of any controlled substance, even prescribed ones as addicts are likely to replace one addiction for another. Methadone, although an opiate, is screened separately from other opiates and does not test positive on general opiate screen. If a patient tests positive for opiates and methadone, he/she is using again. If the test is negative for methadone, one often would suspect that the methadone is not being taken at all, and perhaps being sold for something else. Other common drugs of abuse are tested for as well. In general, repeated "hot" urine's are grounds for dismissal from a clinic but this is not always followed like it should be. We have had several circumstances of patients admitted to the unit who tested positive for several drugs, often freely admitting to using numerous drugs, even returning to IV drug use. When their methadone clinic was notified they stated that they had no intention of discontinuing services. I have had patients who have told me that some clinics never kick a patient out of services. As long as the insurance is paying, the patient gets his methadone.
Eventually patients work their way up to a status where they only need to come in once a week for their methadone and receive a weeks supply at a time. While one hopes that this is because the patient has been compliant and motivated to get well, manipulation is part of the addiction process and many patients given a weeks supply abuse the methadone or sell it for something else.
Suboxone is a newer medication that has been used in treatment of opiate dependence. It is a combination of an opiate with a medication that blocks the absorption of the medication if it is taken IV or snorted. The idea is to discourage misuse of the medication. Its use is not as strictly regulated and can be dispensed by family physicians who have had the training and licensing to prescribe the medication. Physicians are limited on the number of patients they may treat at any time preventing this from being dispensed in a clinic setting. Since the number of patients a given physician may treat is more limited and the monitoring is more easily done, this medication is not abused to nearly the degree that methadone is. Overall the outcomes generally tend to be better and patients on Suboxone do tend to be more compliant. With time, however, people have found ways to get around the opiate blocker and misuse this medication as well. This medication also has a street value in that it prevents withdrawal symptoms for an addict who cannot afford his/her next fix, so it is always worth keeping a tablet or two around. Suboxone is dispensed in one month prescriptions at a time, and many patients take less than they are prescribed and sell the rest so even this is not the perfect answer.
The opiate addiction problem in this city grows daily and as a result, the methadone clinics also grow in number and their locations spread further into remote areas putting more young people are risk of exposure to an unhealthy environment.
None of this is speculation. I work with addicts every day and they tell me the stories about what happens on the street. Sometimes they admit to what is going on, sometimes they do not, but when a patient in methadone maintenance has a drug screen positive for cannibanoids, cocaine and benzodiazepines but no methadone, the patient is not being compliant with treatment. Somehow methadone is being used in a manner it is not supposed to be. And rarely is anything done about it.
Although the city has put in place various drug reporting programs, educational programs and increased security in the schools, as long as there is a continued influx of court ordered addicts and drug pushers from larger cities like New York, Philadelphia and Brooklyn this problem is going to continue to grow. Court ordered treatment rarely does any good. Too many of the persons ordered into treatment choose not to return home, either running from drug gangs or having found a new place to market their deadly product. I hope that city leaders will see what damage that all the drug rehabilitation centers, methadone clinics and halfway houses have done to the city and put a stop to it soon. I am tired of hearing about "mystery people" being found dead of heroin overdoses in public. I am tired of hearing about my teenage patients dying of drug overdoses. And I am tired of dealing with the grief of the parents who have lost a child to drug addiction and not having any comforting words to give them.
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